Nikhil N. Verma, MD

Reverse Total Shoulder Arthroplasty: Indications and Techniques Across the World

Article Type

Article

Changed

Thu, 09/19/2019 - 13:17

Author(s)

Brandon J. Erickson, MD

Daniel D. Bohl, MD, MPH

Brian J. Cole, MBA, MD

Nikhil N. Verma, MD

Gregory Nicholson, MD

Anthony A. Romeo, MD

and Joshua D. Harris, MD

ABSTRACT

Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.

A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.

There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. 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. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

Continue to: Reverse total shoulder arthroplasty...

Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.^1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.^3-5 Al-Hadithy and colleagues⁶ reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues⁷ evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.^3,8,9

The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.^10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.

METHODS

A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.¹² A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).¹³Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine¹⁴) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.

A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).¹⁵

STATISTICAL ANALYSIS

First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.

Continue to: RESULTS...

RESULTS

There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).

Table 1. Demographic Data by Continent

	North America	Europe	Asia	Australia	Total	P-value
Number of studies	52	43	4	4	103	-
Number of subjects	6158	2609	51	155	8973	-
Level of evidence						0.693
II	5 (10%)	3 (7%)	0 (0%)	0 (0%)	8 (8%)
III	10 (19%)	4 (9%)	0 (0%)	1 (25%)	15 (15%)
IV	37 (71%)	36 (84%)	4 (100%)	3 (75%)	80 (78%)
Mean MCMS	34.6 ± 8.4	40.2 ± 8.0	32.5 12.4	34.5 ± 6.6	36.9 ± 8.7	0.010
Institutional collaboration						1.000
Multi-center	7 (14%)	6 (14%)	0 (0%)	0 (0%)	13 (13%)
Single-center	45 (86%)	37 (86%)	4 (100%)	4 (100%)	90 (87%)
Financial conflict of interest						0.005
Present	28 (54%)	15 (35%)	0 (0%)	0 (0%)	43 (42%)
Not present	19 (37%)	16 (37%)	4 (100%)	4 (100%)	43 (42%)
Not reported	5 (10%)	12 (28%)	0 (0%)	0 (0%)	17 (17%)
Sex						N/A
Male	2157 (38%)	1026 (39%)	13 (25%)	61 (39%)	3257 (38%)
Female	3520 (62%)	1622 (61%)	38 (75%)	94 (61%)	5274 (62%)
Mean age (years)	71.3 ± 5.6	70.1 ± 7.9	68.1 ± 5.3	76.9 ± 3.0	70.9 ± 6.7	0.191
Minimum age (mean across studies)	56.9 ± 12.8	52.8 ± 15.7	62.8 ± 6.2	68.0 ± 12.1	55.6 ± 14.3	0.160
Maximum age (mean across studies)	82.1 ± 8.6	83.0 ± 5.5	73.0 ± 9.4	85.0 ± 7.9	82.2 ± 7.6	0.079
Mean length of follow-up (months)	26.5 ± 13.7	43.1 ± 21.7	29.4 ± 7.9	34.2 ± 16.6	34.3 ± 19.3	<0.001
Prosthesis type						N/A
Cemented	988 (89%)	969 (72%)	0 (0%)	8 (16%)	1965 (78%)
Press fit	120 (11%)	379 (28%)	0 (0%)	41 (84%)	540 (22%)

Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.

In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).

Continue to: Rotator cuff tear arthropathy...

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...

DISCUSSION

RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.

RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.¹⁰ This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.¹¹ Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.^16,17 Frankle and colleagues¹⁶ evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues¹⁷evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).

It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.¹⁸ Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.¹⁹ However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.²⁰

Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.^6,21,22

One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.²³ This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.^24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.²⁶ However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.²⁷ With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.

LIMITATIONS

Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.

CONCLUSION

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

This paper will be judged for the Resident Writer’s Award.

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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.

5. De Biase CF, Delcogliano M, Borroni M, Castagna A. Reverse total shoulder arthroplasty: radiological and clinical result using an eccentric glenosphere. Musculoskelet Surg. 2012;96(suppl 1):S27-SS34. doi:10.1007/s12306-012-0193-4.

6. Al-Hadithy N, Domos P, Sewell MD, Pandit R. Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years. J Shoulder Elbow Surg. 2014;23(11):1662-1668. doi:10.1016/j.jse.2014.03.001.

7. Ross M, Hope B, Stokes A, Peters SE, McLeod I, Duke PF. Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly. J Shoulder Elbow Surg. 2015;24(2):215-222. doi:10.1016/j.jse.2014.05.022.

8. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544-2556. doi:10.2106/JBJS.I.00912.

9. Erickson BJ, Frank RM, Harris JD, Mall N, Romeo AA. The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2015;24(6):988-993. doi:10.1016/j.jse.2015.01.001.

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.

12. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34. doi:10.1016/j.jclinepi.2009.06.006.

13. University of York Centre for Reviews and Dissemination, National Institute for Health Research. PROSPERO International prospective register of systematic reviews. University of York Web site. http://www.crd.york.ac.uk/PROSPERO/. Accessed November 1, 2016.

14. Oxford Centre for Evidence-based Medicine – Levels of evidence (March 2009). University of Oxford Web site: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Accessed November 1, 2016.

15. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699. doi:10.2106/JBJS.F.00858.

16. Frankle M, Levy JC, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 Pt 2):178-190. doi:10.2106/JBJS.F.00123.

17. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-1486. doi:10.2106/JBJS.D.02342.

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.

19. Wiater JM, Moravek JE Jr, Budge MD, Koueiter DM, Marcantonio D, Wiater BP. Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up. J Shoulder Elbow Surg. 2014;23(8):1208-1214. doi:10.1016/j.jse.2013.11.032.

20. Nowinski RJ, Gillespie RJ, Shishani Y, Cohen B, Walch G, Gobezie R. Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. J Shoulder Elbow Surg. 2012;21(3):324-328. doi:10.1016/j.jse.2011.08.072.

21. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469(9):2469-2475. doi:10.1007/s11999-011-1833-y.

22. Naveed MA, Kitson J, Bunker TD. The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures. J Bone Joint Surg Br. 2011;93(1):57-61. doi:10.1302/0301-620X.93B1.24218.

23. Ponce BA, Oladeji LO, Rogers ME, Menendez ME. Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs. J Shoulder Elbow Surg. 2015;24(3):460-467. doi:10.1016/j.jse.2014.08.016.

24. Coe MP, Greiwe RM, Joshi R, et al. The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012;21(10):1278-1288. doi:10.1016/j.jse.2011.10.010.

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.

26. Chalmers PN, Slikker W, 3rd, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014;23(2):197-204. doi:10.1016/j.jse.2013.07.044.

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.

Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Erickson reports that he is a Committee Member for the American Orthopaedic Society for Sports Medicine (AOSSM). Dr. Cole reports that he submitted on 07/18/2018; Aesculap/B.Braun, research support; American Journal of Orthopedics, editorial or governing board; American Journal of Sports Medicine, editorial or governing board; Aqua Boom, stock or stock options; Arthrex, Inc, intellectual property (IP) royalties, paid consultant, research support; Arthroscopy, editorial or governing board; Arthroscopy Association of North America, board or committee member; Athletico, other financial or material support; Biomerix, stock or stock options; Cartilage, editorial or governing board; DJ Orthopaedics, IP royalties; Elsevier Publishing, IP royalties; Flexion, paid consultant; Geistlich, research support; Giteliscope, stock or stock options; International Cartilage Repair Society, board or committee member; Journal of Bone and Joint Surgery – American, editor only, editorial or governing board; Journal of Shoulder and Elbow Surgery, editor only, editorial or governing board; Journal of the American Academy of Orthopaedic Surgeons, editor only, editorial or governing board; JRF Ortho, other financial or material support; National Institutes of Health (NIAMS and NICHD), research support; Operative Techniques in Sports Medicine, publishing royalties, financial or material support; Ossio, stock or stock options; Regentis, paid consultant, stock or stock options; Sanofi-Aventis, research support; Smith & Nephew, other financial or material support, paid consultant; Tornier, other financial or material support; and Zimmer Biomet, paid consultant, research support. Dr. Verma reports that he is AOSSM, board or committee member; American Shoulder and Elbow Surgeons, board or committee member; Arthrex, Inc, paid consultant, research support; Arthroscopy, editorial or governing board, publishing royalties, financial or material support; Arthroscopy Association of North America, board or committee member; Arthrosurface, research support; Cymedica, stock or stock options; DJ Orthopaedics, research support; Journal of Knee Surgery, editorial or governing board; Minivasive, paid consultant, stock or stock options; Omeros, stock or stock options; Orthospace, paid consultant; Össur, research support; SLACK Incorporated, editorial or governing board; Smith & Nephew, IP royalties; Smith & Nephew, Athletico, ConMed Linvatec, Miomed, and Mitek, research support; and Vindico Medical-Orthopedics Hyperguide, publishing royalties, financial or material support. Dr. Nicholson reports that he is American Shoulder and Elbow Surgeons, board or committee member; Arthrosurface, paid presenter or speaker; Innomed, IP royalties; Tornier, paid consultant; and Wright Medical Technology, Inc., IP royalties, paid consultant. Dr. Romeo reports that he is American Association of Nurse Anesthetists, other financial or material support; Aesculap/B.Braun, research support; American Shoulder and Elbow Surgeons, board or committee member; Arthrex, Inc, IP royalties, other financial or material support, paid consultant, paid presenter or speaker, research support; Atreon Orthopaedics, board or committee member; Histogenics, research support; Medipost, research support; Major League Baseball, other financial or material support; NuTech, research support; Orthopedics, editorial or governing board; Orthopedics Today, board or committee member, editorial or governing board; OrthoSpace, research support; SAGE, editorial or governing board; Saunders/Mosby-Elsevier, publishing royalties, financial or material support; SLACK Incorporated, editorial or governing board, publishing royalties, financial or material support; Smith & Nephew, research support; Wolters Kluwer Health-Lippincott Williams & Wilkins, editorial or governing board; and Zimmer Biomet, research support. Dr. Harris reports that he is American Academy of Orthopaedic Surgeons, board or committee member; The American Journal of Orthopedics, editorial or governing board; AOSSM, board or committee member; Arthroscopy, editorial or governing board; Arthroscopy Association of North America, board or committee member; DePuy Synthes, A Johnson & Johnson Company, research support; Frontiers In Surgery, editorial or governing board; NIA Magellan, paid consultant; Össur, paid consultant, paid presenter or speaker; SLACK Incorporated, publishing royalties, financial or material support; and Smith & Nephew, paid consultant, paid presenter or speaker, research support. Dr. Bohl reports no actual or potential conflict of interest in relation to this article.

Dr. Erickson is an Attending Surgeon, Sports Medicine and Shoulder Division, Rothman Orthopadic Institute, New York, New York. He was a resident at the time the article was written. Dr. Bohl is an Orthopaedic Surgery Resident, Rush University; Dr. Cole, Dr. Verma, and Dr. Nicholson are Orthopaedic Surgery Attendings, Sports Medicine and Shoulder and Elbow and Sports Division, Midwest Orthopaedics, Rush University Medical Center, Chicago, Illinois. Dr. Romeo is the Managing Partner, Division Chief Shoulder & Elbow and Sports Medicine Department, and Attending Surgeon at Rothman Orthopadics Institute, New York, New York. Dr. Harris is an Orthopaedic Surgery Attending, Sports Medicine Department, Houston Methodist Hospital, Houston, Texas.

Address correspondence to: Brandon J. Erickson, MD, Rothman Orthopaedic Institute, 658 White Plains Road, Tarrytown, NY, 10591 (tel, 800-321-9999; email, brandon.j.erickson@gmail.com).

Brandon J. Erickson, MD Daniel D. Bohl, MD, MPH Brian J. Cole, MBA, MD Nikhil N. Verma, MD Gregory Nicholson, MD Anthony A. Romeo, MD and Joshua D. Harris, MD . Reverse Total Shoulder Arthroplasty: Indications and Techniques Across the World. Am J Orthop.

September 26, 2018

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Arthroplasty/Joint Replacement

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Clinical Review

Author(s)

Brandon J. Erickson, MD

Daniel D. Bohl, MD, MPH

Brian J. Cole, MBA, MD

Nikhil N. Verma, MD

Gregory Nicholson, MD

Anthony A. Romeo, MD

and Joshua D. Harris, MD

Author(s)

Brandon J. Erickson, MD

Daniel D. Bohl, MD, MPH

Brian J. Cole, MBA, MD

Nikhil N. Verma, MD

Gregory Nicholson, MD

Anthony A. Romeo, MD

and Joshua D. Harris, MD

Author and Disclosure Information

Address correspondence to: Brandon J. Erickson, MD, Rothman Orthopaedic Institute, 658 White Plains Road, Tarrytown, NY, 10591 (tel, 800-321-9999; email, brandon.j.erickson@gmail.com).

September 26, 2018

Author and Disclosure Information

Address correspondence to: Brandon J. Erickson, MD, Rothman Orthopaedic Institute, 658 White Plains Road, Tarrytown, NY, 10591 (tel, 800-321-9999; email, brandon.j.erickson@gmail.com).

September 26, 2018

ABSTRACT

Continue to: Reverse total shoulder arthroplasty...

METHODS

STATISTICAL ANALYSIS

Continue to: RESULTS...

RESULTS

Table 1. Demographic Data by Continent

	North America	Europe	Asia	Australia	Total	P-value
Number of studies	52	43	4	4	103	-
Number of subjects	6158	2609	51	155	8973	-
Level of evidence						0.693
II	5 (10%)	3 (7%)	0 (0%)	0 (0%)	8 (8%)
III	10 (19%)	4 (9%)	0 (0%)	1 (25%)	15 (15%)
IV	37 (71%)	36 (84%)	4 (100%)	3 (75%)	80 (78%)
Mean MCMS	34.6 ± 8.4	40.2 ± 8.0	32.5 12.4	34.5 ± 6.6	36.9 ± 8.7	0.010
Institutional collaboration						1.000
Multi-center	7 (14%)	6 (14%)	0 (0%)	0 (0%)	13 (13%)
Single-center	45 (86%)	37 (86%)	4 (100%)	4 (100%)	90 (87%)
Financial conflict of interest						0.005
Present	28 (54%)	15 (35%)	0 (0%)	0 (0%)	43 (42%)
Not present	19 (37%)	16 (37%)	4 (100%)	4 (100%)	43 (42%)
Not reported	5 (10%)	12 (28%)	0 (0%)	0 (0%)	17 (17%)
Sex						N/A
Male	2157 (38%)	1026 (39%)	13 (25%)	61 (39%)	3257 (38%)
Female	3520 (62%)	1622 (61%)	38 (75%)	94 (61%)	5274 (62%)
Mean age (years)	71.3 ± 5.6	70.1 ± 7.9	68.1 ± 5.3	76.9 ± 3.0	70.9 ± 6.7	0.191
Minimum age (mean across studies)	56.9 ± 12.8	52.8 ± 15.7	62.8 ± 6.2	68.0 ± 12.1	55.6 ± 14.3	0.160
Maximum age (mean across studies)	82.1 ± 8.6	83.0 ± 5.5	73.0 ± 9.4	85.0 ± 7.9	82.2 ± 7.6	0.079
Mean length of follow-up (months)	26.5 ± 13.7	43.1 ± 21.7	29.4 ± 7.9	34.2 ± 16.6	34.3 ± 19.3	<0.001
Prosthesis type						N/A
Cemented	988 (89%)	969 (72%)	0 (0%)	8 (16%)	1965 (78%)
Press fit	120 (11%)	379 (28%)	0 (0%)	41 (84%)	540 (22%)

Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.

Continue to: Rotator cuff tear arthropathy...

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.

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

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...

DISCUSSION

LIMITATIONS

CONCLUSION

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Continue to: Reverse total shoulder arthroplasty...

METHODS

STATISTICAL ANALYSIS

Continue to: RESULTS...

RESULTS

Table 1. Demographic Data by Continent

	North America	Europe	Asia	Australia	Total	P-value
Number of studies	52	43	4	4	103	-
Number of subjects	6158	2609	51	155	8973	-
Level of evidence						0.693
II	5 (10%)	3 (7%)	0 (0%)	0 (0%)	8 (8%)
III	10 (19%)	4 (9%)	0 (0%)	1 (25%)	15 (15%)
IV	37 (71%)	36 (84%)	4 (100%)	3 (75%)	80 (78%)
Mean MCMS	34.6 ± 8.4	40.2 ± 8.0	32.5 12.4	34.5 ± 6.6	36.9 ± 8.7	0.010
Institutional collaboration						1.000
Multi-center	7 (14%)	6 (14%)	0 (0%)	0 (0%)	13 (13%)
Single-center	45 (86%)	37 (86%)	4 (100%)	4 (100%)	90 (87%)
Financial conflict of interest						0.005
Present	28 (54%)	15 (35%)	0 (0%)	0 (0%)	43 (42%)
Not present	19 (37%)	16 (37%)	4 (100%)	4 (100%)	43 (42%)
Not reported	5 (10%)	12 (28%)	0 (0%)	0 (0%)	17 (17%)
Sex						N/A
Male	2157 (38%)	1026 (39%)	13 (25%)	61 (39%)	3257 (38%)
Female	3520 (62%)	1622 (61%)	38 (75%)	94 (61%)	5274 (62%)
Mean age (years)	71.3 ± 5.6	70.1 ± 7.9	68.1 ± 5.3	76.9 ± 3.0	70.9 ± 6.7	0.191
Minimum age (mean across studies)	56.9 ± 12.8	52.8 ± 15.7	62.8 ± 6.2	68.0 ± 12.1	55.6 ± 14.3	0.160
Maximum age (mean across studies)	82.1 ± 8.6	83.0 ± 5.5	73.0 ± 9.4	85.0 ± 7.9	82.2 ± 7.6	0.079
Mean length of follow-up (months)	26.5 ± 13.7	43.1 ± 21.7	29.4 ± 7.9	34.2 ± 16.6	34.3 ± 19.3	<0.001
Prosthesis type						N/A
Cemented	988 (89%)	969 (72%)	0 (0%)	8 (16%)	1965 (78%)
Press fit	120 (11%)	379 (28%)	0 (0%)	41 (84%)	540 (22%)

Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.

Continue to: Rotator cuff tear arthropathy...

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.

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

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...

DISCUSSION

LIMITATIONS

CONCLUSION

This paper will be judged for the Resident Writer’s Award.

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.

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.

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TAKE-HOME POINTS

RTSA is an effective treatment for rotator cuff tear arthropathy (the most common reason patients undergo RTSA).
While there has been a plethora of literature surrounding outcomes of RTSA over the past several years, the methodological quality of this literature has been limited.
Similarly, this study found the number of publications surrounding RTSA is increasing each year while the average methodological quality of these studies is decreasing.
Females undergo RTSA more commonly than males, and the average age of patients undergoing RTSA is 71 years.
Interestingly, patients’ postoperative external rotation was higher in studies out of North America compared to other continents. Further research into this area is needed to understand more about this finding.

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Reasons for Readmission Following Primary Total Shoulder Arthroplasty

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Reasons for Readmission Following Primary Total Shoulder Arthroplasty

Author(s)

Gregory L. Cvetanovich, MD

Daniel D. Bohl, MD, MPH

Rachel M. Frank, MD

Nikhil N. Verma, MD

Brian J. Cole, MD, MBA

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

ABSTRACT

An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.

Continue to: Total shoulder arthroplasty...

Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.^1-4 Following the procedure, patients generally achieve shoulder function and pain relief.^5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.^9-16

In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.¹⁷ Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.¹⁸

To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.^19-23 These studies comprised single institution series^20,22 and analyses of administrative databases.^19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.^19-23 However, only limited analyses have been conducted regarding risk factors for readmission.^21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.

This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

METHODS

DATA SOURCE

The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.²⁴ Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.^14,16,25-30

DATA COLLECTION

We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.

The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.

RESTULTS

A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.

Table 1. Patient Population

	Number	Percent
Total	3627	100.0%
Age
18-59	539	14.9%
60-69	1235	34.1%
70-79	1317	36.3%
≥80	536	14.8%
Sex
Male	1603	44.2%
Female	2024	55.8%
Body mass index
Normal (<25 kg/m²)	650	17.9%
Overweight (25-30 kg/m²)	1147	31.6%
Obese (≥30 kg/m²)	1830	50.5%
Functional status
Independent	3544	97.7%
Dependent	83	2.3%
Diabetes mellitus
No	3022	83.3%
Yes	605	16.7%
Dyspnea on exertion
No	3393	93.6%
Yes	234	6.5%
Hypertension
No	1192	32.9%
Yes	2435	67.1%
COPD
No	3384	93.3%
Yes	243	6.7%
Current smoker
No	3249	89.6%
Yes	378	10.4%
Anemia
No	3051	84.1%
Yes	576	15.9%

Abbreviation: COPD, chronic obstructive pulmonary disease.

In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).

Table 2. Bivariate Analysis of Risk Factors for Readmission

	Rate	RR	95% CI	P-value
Age				0.011
18-59	1.30%	Ref.	-
60-69	2.02%	1.6	0.7-3.6
70-79	2.89%	2.2	1.0-4.9
≥80	4.29%	3.3	1.4-7.6
Sex				0.099
Female	2.17%	Ref.	-
Male	3.06%	1.4	0.9-2.1
Body mass index				0.764
Normal (<25 kg/m²)	2.92%	Ref.	-
Overweight (25-30 kg/m²)	2.35%	0.8	0.5-1.4
Obese (≥30 kg/m²)	2.57%	0.9	0.5-1.5
Functional status				0.008
Independent	2.45%	Ref.	-
Dependent	7.23%	2.9	1.3-6.5
Diabetes mellitus				0.483
No	2.48%	Ref.	-
Yes	2.98%	1.2	0.7-2.0
Dyspnea on exertion				0.393
No	2.51%	Ref.	-
Yes	3.42%	1.4	0.7-2.8
Hypertension				0.145
No	2.01%	Ref.	-
Yes	2.83%	1.4	0.9-2.2
COPD				0.457
No	2.51%	Ref.	-
Yes	3.29%	1.3	0.6-2.7
Current smoker				0.116
No	2.71%	Ref.	-
Yes	1.32%	0.5	0.2-1.2
Anemia				<0.001
No	2.16%	Ref.	-
Yes	4.69%	2.2	1.4-3.4

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).

Table 3. Independent Risk Factors for Readmission on Multivariate Analysis

	Rate	RR	95% CI	P-value
Age				0.027
18-59	1.30%	Ref	-
60-69	2.02%	1.6	0.7-3.6
70-79	2.89%	2.3	1.0-5.1
≥80	4.29%	3.1	1.3-7.4
Sex				0.025
Female	2.17%	Ref.	-
Male	3.06%	1.6	1.1-2.4
Anemia				0.005
No	2.16%	Ref	-
Yes	4.69%	1.9	1.2-3.0
Functional status				0.012
Independent	2.45%	Ref	-
Dependent	7.23%	2.8	1.3-6.2

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Continue to: Table 4...

The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).

Table 4. Reasons for Readmission

	Number	Percent
Pneumonia	14	16.7%
Dislocation	7	8.3%
Pulmonary embolism	7	8.3%
Surgical site infection	6	7.1%
Atrial fibrillation	4	4.8%
Hematoma	4	4.8%
Altered mental status	3	3.6%
Chest pain	3	3.6%
Renal insufficiency/kidney failure	3	3.6%
Urinary tract infection	3	3.6%
Acute gastric or duodenal ulcer	2	2.4%
Dermatitis/other allergic reaction	2	2.4%
Orthostatic hypotension/syncope	2	2.4%
Pain	2	2.4%
Respiratory distress	2	2.4%
Sepsis	2	2.4%
Urinary retention	2	2.4%
Acute cholecystitis	1	1.2%
Cerebrovascular accident	1	1.2%
Constipation	1	1.2%
Contusion of shoulder	1	1.2%
Deep venous thrombosis requiring therapy	1	1.2%
Gastrointestinal hemorrhage	1	1.2%
Gout	1	1.2%
Hepatic encephalopathy	1	1.2%
Intestinal infection	1	1.2%
Narcotic overdose	1	1.2%
Nausea/vomiting	1	1.2%
Proximal humerus fracture	1	1.2%
Rotator cuff tear	1	1.2%
Seroma	1	1.2%
Unspecified disease of pericardium	1	1.2%
Weakness	1	1.2%

DISCUSSION

Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.

In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.^17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.^19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues²⁰retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues²² evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.

Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues¹⁹ used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues²¹ used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues²³ used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues³¹ analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.

This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;^20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.¹⁸Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.

Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.³² By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.

CONCLUSION

Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.

This paper will be judged for the Resident Writer’s Award.

References

Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
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. doi:10.2106/JBJS.J.01994.
Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.

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Author and Disclosure Information

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The authors report no actual or potential conflict of interest in relation to this article.

Dr. Cvetanovich is a Sports Medicine Fellow, Dr. Bohl is a Resident, Dr. Verma and Dr. Cole are Professors, and Dr. Nicholson is an Associate Professor, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois. Dr. Frank is an Assistant Professor, University of Colorado, Aurora, Colorado. Dr. Romeo is Chief of Orthopaedics, Rothman Institute, New York. Dr. Cvetanovich was a resident at the time the article was written.

Address correspondence to: Gregory L. Cvetanovich, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612 (tel, 312-243-4244; fax, 708-409-5179; email, Gregory.cvetanovich@gmail.com).

Gregory L. Cvetanovich, MD Daniel D. Bohl, MD, MPH Rachel M. Frank, MD Nikhil N. Verma, MD Brian J. Cole, MD, MBA Gregory P. Nicholson, MD Anthony A. Romeo, MD . Reasons for Readmission Following Primary Total Shoulder Arthroplasty. Am J Orthop. July 6, 2018

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The American Journal of Orthopedics

Topics

Shoulder & Elbow

Arthroplasty/Joint Replacement

Orthopedics

Read more about Reasons for Readmission Following Primary Total Shoulder Arthroplasty

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Original Research

Author(s)

Gregory L. Cvetanovich, MD

Daniel D. Bohl, MD, MPH

Rachel M. Frank, MD

Nikhil N. Verma, MD

Brian J. Cole, MD, MBA

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Author(s)

Gregory L. Cvetanovich, MD

Daniel D. Bohl, MD, MPH

Rachel M. Frank, MD

Nikhil N. Verma, MD

Brian J. Cole, MD, MBA

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

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ajo_-_reasons_for_readmission_following_primary_total_shoulder_arthroplasty_-_2018-07-06.pdf

ABSTRACT

Continue to: Total shoulder arthroplasty...

METHODS

DATA SOURCE

DATA COLLECTION

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESTULTS

Table 1. Patient Population

	Number	Percent
Total	3627	100.0%
Age
18-59	539	14.9%
60-69	1235	34.1%
70-79	1317	36.3%
≥80	536	14.8%
Sex
Male	1603	44.2%
Female	2024	55.8%
Body mass index
Normal (<25 kg/m²)	650	17.9%
Overweight (25-30 kg/m²)	1147	31.6%
Obese (≥30 kg/m²)	1830	50.5%
Functional status
Independent	3544	97.7%
Dependent	83	2.3%
Diabetes mellitus
No	3022	83.3%
Yes	605	16.7%
Dyspnea on exertion
No	3393	93.6%
Yes	234	6.5%
Hypertension
No	1192	32.9%
Yes	2435	67.1%
COPD
No	3384	93.3%
Yes	243	6.7%
Current smoker
No	3249	89.6%
Yes	378	10.4%
Anemia
No	3051	84.1%
Yes	576	15.9%

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 2. Bivariate Analysis of Risk Factors for Readmission

	Rate	RR	95% CI	P-value
Age				0.011
18-59	1.30%	Ref.	-
60-69	2.02%	1.6	0.7-3.6
70-79	2.89%	2.2	1.0-4.9
≥80	4.29%	3.3	1.4-7.6
Sex				0.099
Female	2.17%	Ref.	-
Male	3.06%	1.4	0.9-2.1
Body mass index				0.764
Normal (<25 kg/m²)	2.92%	Ref.	-
Overweight (25-30 kg/m²)	2.35%	0.8	0.5-1.4
Obese (≥30 kg/m²)	2.57%	0.9	0.5-1.5
Functional status				0.008
Independent	2.45%	Ref.	-
Dependent	7.23%	2.9	1.3-6.5
Diabetes mellitus				0.483
No	2.48%	Ref.	-
Yes	2.98%	1.2	0.7-2.0
Dyspnea on exertion				0.393
No	2.51%	Ref.	-
Yes	3.42%	1.4	0.7-2.8
Hypertension				0.145
No	2.01%	Ref.	-
Yes	2.83%	1.4	0.9-2.2
COPD				0.457
No	2.51%	Ref.	-
Yes	3.29%	1.3	0.6-2.7
Current smoker				0.116
No	2.71%	Ref.	-
Yes	1.32%	0.5	0.2-1.2
Anemia				<0.001
No	2.16%	Ref.	-
Yes	4.69%	2.2	1.4-3.4

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Table 3. Independent Risk Factors for Readmission on Multivariate Analysis

	Rate	RR	95% CI	P-value
Age				0.027
18-59	1.30%	Ref	-
60-69	2.02%	1.6	0.7-3.6
70-79	2.89%	2.3	1.0-5.1
≥80	4.29%	3.1	1.3-7.4
Sex				0.025
Female	2.17%	Ref.	-
Male	3.06%	1.6	1.1-2.4
Anemia				0.005
No	2.16%	Ref	-
Yes	4.69%	1.9	1.2-3.0
Functional status				0.012
Independent	2.45%	Ref	-
Dependent	7.23%	2.8	1.3-6.2

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Continue to: Table 4...

Table 4. Reasons for Readmission

	Number	Percent
Pneumonia	14	16.7%
Dislocation	7	8.3%
Pulmonary embolism	7	8.3%
Surgical site infection	6	7.1%
Atrial fibrillation	4	4.8%
Hematoma	4	4.8%
Altered mental status	3	3.6%
Chest pain	3	3.6%
Renal insufficiency/kidney failure	3	3.6%
Urinary tract infection	3	3.6%
Acute gastric or duodenal ulcer	2	2.4%
Dermatitis/other allergic reaction	2	2.4%
Orthostatic hypotension/syncope	2	2.4%
Pain	2	2.4%
Respiratory distress	2	2.4%
Sepsis	2	2.4%
Urinary retention	2	2.4%
Acute cholecystitis	1	1.2%
Cerebrovascular accident	1	1.2%
Constipation	1	1.2%
Contusion of shoulder	1	1.2%
Deep venous thrombosis requiring therapy	1	1.2%
Gastrointestinal hemorrhage	1	1.2%
Gout	1	1.2%
Hepatic encephalopathy	1	1.2%
Intestinal infection	1	1.2%
Narcotic overdose	1	1.2%
Nausea/vomiting	1	1.2%
Proximal humerus fracture	1	1.2%
Rotator cuff tear	1	1.2%
Seroma	1	1.2%
Unspecified disease of pericardium	1	1.2%
Weakness	1	1.2%

DISCUSSION

CONCLUSION

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Continue to: Total shoulder arthroplasty...

METHODS

DATA SOURCE

DATA COLLECTION

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESTULTS

Table 1. Patient Population

	Number	Percent
Total	3627	100.0%
Age
18-59	539	14.9%
60-69	1235	34.1%
70-79	1317	36.3%
≥80	536	14.8%
Sex
Male	1603	44.2%
Female	2024	55.8%
Body mass index
Normal (<25 kg/m²)	650	17.9%
Overweight (25-30 kg/m²)	1147	31.6%
Obese (≥30 kg/m²)	1830	50.5%
Functional status
Independent	3544	97.7%
Dependent	83	2.3%
Diabetes mellitus
No	3022	83.3%
Yes	605	16.7%
Dyspnea on exertion
No	3393	93.6%
Yes	234	6.5%
Hypertension
No	1192	32.9%
Yes	2435	67.1%
COPD
No	3384	93.3%
Yes	243	6.7%
Current smoker
No	3249	89.6%
Yes	378	10.4%
Anemia
No	3051	84.1%
Yes	576	15.9%

Abbreviation: COPD, chronic obstructive pulmonary disease.

Table 2. Bivariate Analysis of Risk Factors for Readmission

	Rate	RR	95% CI	P-value
Age				0.011
18-59	1.30%	Ref.	-
60-69	2.02%	1.6	0.7-3.6
70-79	2.89%	2.2	1.0-4.9
≥80	4.29%	3.3	1.4-7.6
Sex				0.099
Female	2.17%	Ref.	-
Male	3.06%	1.4	0.9-2.1
Body mass index				0.764
Normal (<25 kg/m²)	2.92%	Ref.	-
Overweight (25-30 kg/m²)	2.35%	0.8	0.5-1.4
Obese (≥30 kg/m²)	2.57%	0.9	0.5-1.5
Functional status				0.008
Independent	2.45%	Ref.	-
Dependent	7.23%	2.9	1.3-6.5
Diabetes mellitus				0.483
No	2.48%	Ref.	-
Yes	2.98%	1.2	0.7-2.0
Dyspnea on exertion				0.393
No	2.51%	Ref.	-
Yes	3.42%	1.4	0.7-2.8
Hypertension				0.145
No	2.01%	Ref.	-
Yes	2.83%	1.4	0.9-2.2
COPD				0.457
No	2.51%	Ref.	-
Yes	3.29%	1.3	0.6-2.7
Current smoker				0.116
No	2.71%	Ref.	-
Yes	1.32%	0.5	0.2-1.2
Anemia				<0.001
No	2.16%	Ref.	-
Yes	4.69%	2.2	1.4-3.4

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Table 3. Independent Risk Factors for Readmission on Multivariate Analysis

	Rate	RR	95% CI	P-value
Age				0.027
18-59	1.30%	Ref	-
60-69	2.02%	1.6	0.7-3.6
70-79	2.89%	2.3	1.0-5.1
≥80	4.29%	3.1	1.3-7.4
Sex				0.025
Female	2.17%	Ref.	-
Male	3.06%	1.6	1.1-2.4
Anemia				0.005
No	2.16%	Ref	-
Yes	4.69%	1.9	1.2-3.0
Functional status				0.012
Independent	2.45%	Ref	-
Dependent	7.23%	2.8	1.3-6.2

Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.

Continue to: Table 4...

Table 4. Reasons for Readmission

	Number	Percent
Pneumonia	14	16.7%
Dislocation	7	8.3%
Pulmonary embolism	7	8.3%
Surgical site infection	6	7.1%
Atrial fibrillation	4	4.8%
Hematoma	4	4.8%
Altered mental status	3	3.6%
Chest pain	3	3.6%
Renal insufficiency/kidney failure	3	3.6%
Urinary tract infection	3	3.6%
Acute gastric or duodenal ulcer	2	2.4%
Dermatitis/other allergic reaction	2	2.4%
Orthostatic hypotension/syncope	2	2.4%
Pain	2	2.4%
Respiratory distress	2	2.4%
Sepsis	2	2.4%
Urinary retention	2	2.4%
Acute cholecystitis	1	1.2%
Cerebrovascular accident	1	1.2%
Constipation	1	1.2%
Contusion of shoulder	1	1.2%
Deep venous thrombosis requiring therapy	1	1.2%
Gastrointestinal hemorrhage	1	1.2%
Gout	1	1.2%
Hepatic encephalopathy	1	1.2%
Intestinal infection	1	1.2%
Narcotic overdose	1	1.2%
Nausea/vomiting	1	1.2%
Proximal humerus fracture	1	1.2%
Rotator cuff tear	1	1.2%
Seroma	1	1.2%
Unspecified disease of pericardium	1	1.2%
Weakness	1	1.2%

DISCUSSION

CONCLUSION

This paper will be judged for the Resident Writer’s Award.

References

Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
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. doi:10.2106/JBJS.J.01994.
Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.

References

Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
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. doi:10.2106/JBJS.J.01994.
Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.

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Reasons for Readmission Following Primary Total Shoulder Arthroplasty

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Shoulder arthroplasty is an increasingly commonly performed procedure for shoulder arthritis and other conditions.
Unplanned readmission in the 30 days after shoulder arthroplasty occurred in about 1 of 40 cases.
Increasing age was associated with readmission, particularly age >80 years.
Other risk factors for readmission were male sex, anemia, and dependent functional status.
The most common reasons for readmission were pneumonia, dislocation, pulmonary embolism, and surgical site infection.

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

Author(s)

Timothy S. Leroux, MD

Bryce A. Basques, MD

Bryan M. Saltzman, MD

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

ABSTRACT

It has been suggested that the utilization of joint arthroplasty in patients with rheumatoid arthritis (RA) is decreasing; however, this observation is largely based upon evidence pertaining to lower-extremity joint arthroplasty. It remains unknown if these observed trends also hold true for shoulder arthroplasty. The purpose of this study is to utilize a nationally representative population database in the US to identify trends in the utilization of shoulder arthroplasty among patients with RA. Secondarily, we sought to determine the rate of early adverse events, length of stay, and hospitalization costs associated with RA patients undergoing shoulder arthroplasty and to compare these outcomes to those of patients without a diagnosis of RA undergoing shoulder arthroplasty. Using a large population database in the US, we determined the annual rates of shoulder arthroplasty (overall and individual) in RA patients between 2002 and 2011. Early adverse events, length of stay, and hospitalization costs were determined and compared with those of non-RA patients undergoing shoulder arthroplasty. Overall, we identified 332,593 patients who underwent shoulder arthroplasty between 2002 and 2011, of whom 17,883 patients (5.4%) had a diagnosis of RA. Over the study period, there was a significant increase in the utilization of shoulder arthroplasty in RA patients, particularly total shoulder arthroplasty. Over the same period, there was a significant increase in the number of RA patients who underwent shoulder arthroplasty with a diagnosis of rotator cuff disease. There were no significant differences in adverse events or mean hospitalization costs between RA and non-RA patients. Non-RA patients had a significantly shorter length of stay; however, the difference did not appear to be clinically significant. In conclusion, the utilization of shoulder arthroplasty in patients with RA significantly increased from 2002 to 2011, which may partly reflect a trend toward management of rotator cuff disease with arthroplasty rather than repair.

Continue to: It has been suggested...

It has been suggested that the utilization of total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA) is decreasing over time;¹ however, this observation is largely based upon evidence pertaining to lower extremity TJA.² It remains unknown if these observed trends also hold true for shoulder arthroplasty, whereby the utilization of shoulder arthroplasty in RA patients is not limited to the management of end-stage inflammatory arthropathy. In this study, we used a nationally representative population database in the US to identify trends in the utilization of shoulder arthroplasty among patients with RA. As a secondary objective, we sought to determine the rate of early adverse events, length of stay, and hospitalization costs associated with RA patients undergoing shoulder arthroplasty and compare these outcomes to those of patients without a diagnosis of RA undergoing shoulder arthroplasty. We hypothesize that the utilization of shoulder arthroplasty in RA patients would be decreasing, but adverse events, length of stay, and hospitalization costs would not differ between patients with and without RA undergoing shoulder arthroplasty.

METHODS

We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) from 2002 to 2011.³ The NIS comprises a 20% stratified sample of all hospital discharges in the US. The NIS includes information about patient characteristics (age, sex, insurance status, and medical comorbidities) and hospitalization outcomes (adverse events, costs, and length of stay). The NIS allows identification of hospitalizations according to procedures and diagnoses using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Given the anonymity of this study, it was exempt from Institutional Review Board ethics approval.

Hospitalizations were selected for the study based on ICD-9-CM procedural codes for hemiarthroplasty (81.81), anatomic total shoulder arthroplasty (TSA) (81.80), and reverse TSA (81.88). These patients were then stratified by an ICD-9-CM diagnosis of RA (714.X). We also utilized ICD-9-CM diagnosis codes to determine the presence of rotator cuff pathology at the time of shoulder arthroplasty (726.13, 727.61, 840.4) and to exclude patients with a history of trauma (812.X, 716.11, 733.8X). In a separate analysis, all patients in the NIS database with an ICD-9-CM diagnosis of RA were identified for each calendar year of the study, and a national estimate of RA patients was generated annually to assess overall and individual utilization rates of shoulder arthroplasty in this population (the national estimate served as the denominator).

Preoperative patient data withdrawn from the NIS included age, sex, insurance status, and medical comorbidities. An Elixhauser Comorbidity Index (ECI) was generated for each patient based on the presence of 29 comorbid conditions. The ECI was chosen because of its capacity to accurately predict mortality and represent the patient burden of comorbidities in similar administrative database studies.^4-6

Early adverse events were also chosen based on ICD-9-CM diagnosis codes (Appendix A), and included the following: death, acute kidney injury, cardiac arrest, thromboembolic event, myocardial infarction, peripheral nerve injury, pneumonia, sepsis, stroke, surgical site infection, urinary tract infection, and wound dehiscence. The overall adverse event rate was defined as the occurrence of ≥1 of the above adverse events in a patient.

Appendix A. ICD-9-CM Codes Corresponding to Postoperative Adverse Events

Event	*ICD-9-CM*
Acute kidney injury	584.5-584.9
Cardiac arrest	427.41, 427.5
Thromboembolic event	453.2-453.4, 453.82-453.86, 415.1
Myocardial Infarction	410.00-410.92
Peripheral nerve injury	953.0-953.9 954.0-954.9, 955.0-955.9, 956.0-956.9
Pneumonia	480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 484.1-484.8, 485, 486
Sepsis	038.0-038.9, 112.5, 785.52, 995.91, 995.92
Stroke	430, 432, 433.01-434.91, 997.02
Surgical site infection	998.51, 998.59, 996.67
Urinary tract infection	599
Wound dehiscence	998.30-998.33

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

Length of stay and total hospital charges were available for each patient. Length of stay represents the number of calendar days a patient stayed in the hospital. All hospital charges were converted to hospitalization costs using the HCUP Cost-to-Charge Ratio Files. All hospitalization costs were adjusted for inflation using the US Bureau of Labor statistics yearly inflation calculator to represent charges in the year 2011, which was the final and most recent year in this study.

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

Statistical analyses were conducted using Stata version 13.1 (StataCorp, LP). All analyses took into account the complex survey design of the NIS. Discharge weights, strata, and cluster variables were included to correctly estimate variance and to produce national estimates from the stratified sample. Pearson’s chi-squared test was used to compare age, sex, ECI, and insurance status between RA and non-RA patients undergoing shoulder arthroplasty.

Bivariate and multivariate logistic regressions were subsequently used to compare the rates of adverse events between RA and non-RA patients undergoing shoulder arthroplasty (non-RA cases were used as the reference). Multivariate linear regressions were used to compare hospital length of stay and hospitalization costs between RA and non-RA patients undergoing shoulder arthroplasty. The multivariate regressions were adjusted for baseline differences in age, sex, ECI, and insurance status. Cochran-Armitage tests for trend were used to assess trends over time. All tests were 2-tailed, and the statistical difference was established at a 2-sided α level of 0.05 (P < .05).

RESULTS

Overall, we identified 332,593 patients who underwent shoulder arthroplasty in the US between 2002 and 2011, of which 17,883 patients (5.4%) had a diagnosis of RA. In comparison with non-RA patients undergoing shoulder arthroplasty, patients with RA at the time of shoulder arthroplasty were significantly younger (65.2 ± 12.5 years vs 68.4 ± 11.0 years, P < .001), included a significantly greater proportion of female patients (76.7% vs 53.8%, P < .001), and included a significantly higher proportion of patients with Medicaid insurance (3.6% vs 2.3%, P < .001). There were no significant differences in the mean ECI between patients with and without a diagnosis of RA (Table 1). As depicted in Table 1, there were significant differences in the utilization of specific shoulder arthroplasty types between patients with and without RA, whereby a significantly greater proportion of RA patients underwent hemiarthroplasty (HA) (31.6% vs 29.3%, P = .002) and reverse TSA (7.7% vs 6.6%, P = .002), whereas a significantly greater proportion of non-RA patients underwent anatomic SA (64.0% vs 60.8%, P = .002).

Over the study period from 2002 to 2011, there was a significant increase in the overall utilization of shoulder arthroplasty in RA patients, as indicated by both the absolute number and the proportion of patients with a diagnosis of RA (P < .001) (Table 2, Figure). More specifically, 0.39% of RA patients underwent shoulder arthroplasty in 2002, as compared with 0.58% of RA patients in 2011 (P < .001) (Table 2). With respect to specific arthroplasty types, there was an exponential rise in the utilization of reverse TSA beginning in 2010 and a corresponding decrease in the rates of both HA and anatomic TSA (Table 2, Figure). In addition to changes in shoulder arthroplasty utilization over time among RA patients, we also observed a significant increase in the number of RA patients undergoing shoulder arthroplasty with a corresponding diagnosis of rotator cuff disease (9.7% in 2002 to 15.2% in 2011, P < .001).

Table 2. The Annual Utilization of Shoulder Arthroplasty Among Patients with a Diagnosis of Rheumatoid Arthritis.

Proportion of RA patients
Year	Overall Rate of Shoulder Arthroplasty^a	HA	Anatomic TSA	Reverse TSA
2002	0.39	0.23	0.16	0
2003	0.37	0.19	0.18	0
2004	0.46	0.25	0.21	0
2005	0.46	0.21	0.25	0
2006	0.47	0.20	0.27	0
2007	0.55	0.22	0.33	0
2008	0.47	0.17	0.30	0
2009	0.50	0.15	0.35	0
2010	0.58	0.15	0.37	0.06
2011	0.58	0.12	0.23	0.23
Absolute number of RA patients
2002	1295	768	527	0
2003	1247	650	597	0
2004	1667	906	761	0
2005	1722	776	946	0
2006	1847	794	1053	0
2007	2249	910	1339	0
2008	2194	799	1395	0
2009	2407	724	1683	0
2010	2869	722	1857	290
2011	3193	649	1261	1283

^aRate determined as number of RA patients undergoing shoulder arthroplasty compared to the number of patients with an RA diagnosis in the stated calendar year.

Abbreviations: HA, hemiarthroplasty; RA, rheumatoid arthritis; TSA, total shoulder arthroplasty.

Continue to: Among patients with RA...

Among patients with RA undergoing shoulder arthroplasty, the overall rate of early adverse events was 3.12%, of which the most common early adverse events were urinary tract infections (1.8%), acute kidney injury (0.66%), and pneumonia (0.38%) (Table 3). As compared with patients without a diagnosis of RA undergoing shoulder arthroplasty, there were no significant differences in the overall and individual rates of early adverse events (Table 3).

Table 3. A Comparison of Early Adverse Events, Length of Stay, and Cost Between Patients With and Without Rheumatoid Arthritis (RA) Undergoing Shoulder Arthroplasty

Comparison of Early Adverse Event Rates
	Non-RA Patients	RA Patients	Multivariate Logistic Regression
	Non-RA Patients	RA Patients	Odds Ratio	P-Value
Overall adverse event rate	3.02%	3.12%	1.0	0.83
Specific adverse event rate
Death	0.08%	0.05%	0.9	0.91
Acute kidney injury	0.85%	0.66%	0.9	0.59
Cardiac arrest	0.05%	0.05%	1.3	0.70
Thromboembolic event	0.01%	0.00%	-	-
Myocardial Infarction	0.22%	0.06%	0.4	0.17
Peripheral nerve injury	0.08%	0.11%	1.5	0.45
Pneumonia	0.47%	0.38%	0.9	0.70
Sepsis	0.08%	0.08%	1.3	0.62
Stroke	0.07%	0.05%	0.9	0.93
Surgical site infection	0.09%	0.13%	1.4	0.52
Urinary tract infection	1.44%	1.80%	1.1	0.46
Wound dehiscence	0.01%	0.05%	3.6	0.09
Comparison of Length of Stay and Hospital Charges
	Non-RA Patients (percent)	RA Patients (percent)	Multivariate Linear Regression
	Non-RA Patients (percent)	RA Patients (percent)	Beta	P-Value
Length of stay^a	2.3±2.0	2.4±1.6	+0.1	0.002
Hospitalization cost^b	14,826±8,336	14,787±7,625	+93	0.59

^aReported in days. ^bReported in 2011 US dollars, adjusted for inflation.

The mean length of stay following shoulder arthroplasty in RA patients was 2.4 ± 1.6 days, and the mean hospitalization cost was $14,787 ± $7625 (Table 3). As compared with non-RA patients undergoing shoulder arthroplasty, there were no significant differences in the mean hospitalization costs; however, non-RA patients had a significantly shorter length of stay by 0.1 days (P = .002) (Table 3).

DISCUSSION

In this study, we observed that the utilization of shoulder arthroplasty in patients with RA increased significantly in the decade from 2002 to 2011, largely related to a rise in TSA. Interestingly, we also observed a corresponding rise in the proportion of RA patients undergoing shoulder arthroplasty with a diagnosis of rotator cuff disease, and we believe that this may partly account for the recent increase in the use of the reverse TSA in this patient population. Additionally, we found shoulder arthroplasty in RA patients to be safe in the early postoperative period, with no significant increase in cost as compared with patients undergoing shoulder arthroplasty without a diagnosis of RA. Although we did observe a significant increase in length of stay among RA patients as compared with non-RA patients, the absolute difference was only 0.1 days, and given the aforementioned similarities in cost between RA and non-RA patients, we do not believe this difference to be clinically significant.

It has been theorized that the utilization of TJA in RA patients has been decreasing with improvements in medical management; however, this is largely based upon literature pertaining to lower extremity TJA.² On the contrary, past research pertaining to the utilization of shoulder arthroplasty in RA patients has been highly variable. For instance, a Swedish study demonstrated a statistically significant decrease in admissions associated with RA-related upper limb surgery and a stable rate of shoulder arthroplasty between 1998 and 2004.⁷ Similarly, a Finnish study demonstrated that the annual incidence of primary joint arthroplasty in RA patients had declined from 1995 to 2010, with a greater decline for upper-limb arthroplasty as compared with lower-limb arthroplasty.⁸ Despite these European observations, Jain and colleagues⁹ reported an increasing rate of TSA among RA patients in the US between the years 1992 and 2005. In this study, we demonstrate a clear increase in the utilization of shoulder arthroplasty among RA patients between 2002 and 2011. What was most striking about our observation was that the rise in utilization appeared to be driven by an increase in TSA, whereas the utilization of HA decreased over time. This change in practice likely reflects several factors, including the multitude of studies that have demonstrated improved outcomes with anatomic TSA as compared with HA in RA patients.^10-14

Perhaps the most interesting aspect of our data was the recent exponential rise in the utilization of the reverse TSA. Despite improved outcomes following TSA as compared with HA in RA patients, these outcomes all appear to be highly dependent upon the integrity of the rotator cuff.¹⁰ In fact, there is evidence that failure of the rotator cuff could be as high as 75% within 10 years of TSA in patients with RA,¹⁵ which ultimately could jeopardize the long-term durability of the TSA implant in this patient population.¹¹ For this reason, interest in the reverse TSA for the RA patient population has increased since its introduction in the US in 2004;¹⁶ in fact, in RA patients with end-stage inflammatory arthropathy and a damaged rotator cuff, the reverse TSA has demonstrated excellent results.^17-20 Based upon this evidence, it is not surprising that we found an exponential rise in the use of the reverse TSA since 2010, which corresponds to the introduction of an ICD-9 code for this implant.²¹ Prior to 2010, it is likely that many implanted reverse TSAs were coded as TSA, and for this reason, we believe that the observed rise in the utilization of TSA in RA patients prior to 2010 may have been partly fueled by an increase in the use of the reverse TSA. To further support this theory, there was a dramatic decrease in the use of anatomic TSA following 2010, and we believe this was related to increased awareness of the newly introduced reverse TSA code among surgeons.

Another consideration when examining the utilization of shoulder arthroplasty in RA patients is its versatility in managing different disease states, including rotator cuff disease. As has been documented in the literature, outcomes of rotator cuff repair in RA patients are discouraging.²² For this reason, it is reasonable for surgeons and patients with RA to consider alternatives to rotator cuff repair when nonoperative management has failed to provide adequate improvement in symptoms. One alternative may be shoulder arthroplasty, namely the reverse TSA. In this study, we observed a significant increase in the rate of diagnosis of rotator cuff disease among RA patients undergoing shoulder arthroplasty from 2002 to 2011 (9.7% in 2002 to 15.2% in 2011, P < .001), and it is our belief that the simultaneous increase in the diagnosis of rotator cuff disease and use of TSA is not coincidental. More specifically, there is likely an emerging trend among surgeons toward using the reverse TSA to manage rotator cuff tears in the RA population, rather than undertaking a rotator cuff repair that carries a high rate of failure. Going forward, there is a need to not only identify this trend more clearly but to also compare the outcomes between reverse TSA and rotator cuff repair in the management of rotator cuff tears in RA patients.

Continue to: In this study, we observed...

In this study, we observed that RA patients undergoing shoulder arthroplasty were significantly younger than non-RA patients undergoing shoulder arthroplasty. At first, this observation seems to counter recent literature suggesting that the age of patients with inflammatory arthropathy undergoing TJA is increasing over time;¹ however, looking more closely at the data, it becomes clearer that the mean age we report is actually a relative increase as compared with past clinical studies pertaining to RA patients undergoing shoulder arthroplasty (mean ages of 47 years,²³ 55 years,²⁴ 60 years,¹⁰ and 62 years²⁵). On the other hand, the continued existence of an age gap between RA and non-RA patients undergoing shoulder arthroplasty may be the result of several possible phenomena. First, this may reflect issues with patient access to and coverage of expensive biologic antirheumatic medication that would otherwise mitigate disease progression. For instance, the out-of-pocket expense for biologic medication through Medicaid and Medicare is substantial,²⁶which has direct implications on over two-thirds of our RA cohort. Second, it may be skewed by the proportion of RA patients who have previously been or continue to be poorly managed, enabling disease progression to end-stage arthropathy at a younger age. Ultimately, further investigation is needed to determine the reasons for this continued age disparity.

In comparing RA and non-RA patients undergoing shoulder arthroplasty, we did not find a significant difference in the overall nor the individual rates of early adverse events. This finding appears to be unique, as similar studies pertaining to total knee arthroplasty (TKA) demonstrated a significantly higher incidence of postoperative pneumonia and bleeding requiring transfusion among RA patients as compared with non-RA patients.²⁷ In patients with RA being treated with biologic medication and undergoing shoulder arthroplasty, the frequent concern in the postoperative period is the integrity of the wound and the potential for infection.²⁸ In this study, we did not find a significant difference in the rate of early infection, and although the difference in the rate of early wound dehiscence approached significance, it did not meet the threshold of 0.05 (P = .09). This finding is in keeping with the aforementioned NIS study pertaining to TKA, and we believe that it likely reflects the short duration of follow-up for patients in both studies. Given the nature of the database we utilized, we were only privy to complications that arose during the inpatient hospital stay, and it is likely that the clear majority of patients who develop a postoperative infection or wound dehiscence do so in the postoperative setting following discharge. A second concern regarding postoperative wound complications is the management of biologic medication in the perioperative period, which we cannot determine using this database. Despite all these limitations specific to this database, a past systematic review of reverse TSA in RA patients found a low rate of deep infection after reverse TSA in RA patients (3.3%),¹⁷ which was not higher than that after shoulder arthroplasty performed in non-RA patients.

A final demonstration from this study is that the hospital length of stay was significantly longer for RA patients than non-RA patients undergoing shoulder arthroplasty; however, given that the difference was only 0.1 days, and there was no significant difference in hospitalization cost, we are inclined to believe that statistical significance may not translate into clinical significance in this scenario. Ultimately, we do believe that length of stay is an important consideration in the current healthcare system, and given our finding that shoulder arthroplasty in the RA patient is safe in the early postoperative period, that a prolonged postoperative hospitalization is not warranted on the sole basis of a patient’s history of RA.

As with all studies using data from a search of an administrative database, such as the NIS database, this study has limitations. First, this type of research is limited by the reliability of both diagnosis and procedural coding. Although the NIS database has demonstrated high reliability,³ it is still possible that events may have been miscoded. Second, the tracking period for adverse events is limited to the inpatient hospital stay, which may be too short to detect certain postoperative complications. As such, the rates we report are likely underestimates of the true incidence of these complications, but this is true for both the RA and non-RA populations. Third, the comparisons we draw between RA and non-RA patients are limited to the scope of the NIS database and the available data; as such, we could not draw comparisons between preoperative disease stage, intraoperative findings, and postoperative course following hospital discharge. Lastly, our data are limited to a distinct period between 2002 and 2011 and may not reflect current practice. Ultimately, our findings may underestimate current trends in shoulder arthroplasty utilization among RA patients, particularly for the reverse TSA.

CONCLUSION

In this study, we found that the utilization of shoulder arthroplasty in patients with RA increased significantly from 2002 to 2011, largely related to a rise in the utilization of TSA. Similarly, we observed a rise in the proportion of RA patients undergoing shoulder arthroplasty with a corresponding diagnosis of rotator cuff disease, and we believe the increased utilization of shoulder arthroplasty among RA patients resulted from management of both end-stage inflammatory arthropathy and rotator cuff disease. Although we did not find a significant difference between RA and non-RA patients in the rates of early adverse events and overall hospitalization costs following shoulder arthroplasty, length of stay was significantly longer among RA patients; however, the absolute difference does not appear to be clinically significant.

References

Mertelsmann-Voss C, Lyman S, Pan TJ, Goodman SM, Figgie MP, Mandl LA. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014;66(6):1432-1439. doi:10.1002/art.38384.
Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis. 2010;69(5):868-871. doi:10.1136/ard.2009.112474.
HCUP Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality; 2002-2011.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004.
Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109-1118. doi:10.1097/MLR.0b013e31825f64d0.
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5.
Weiss RJ, Ehlin A, Montgomery SM, Wick MC, Stark A, Wretenberg P. Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatol Oxf. 2008 ;47(4):491-494. doi. 10.1093/rheumatology/ken009.
Jämsen E, Virta LJ, Hakala M, Kauppi MJ, Malmivaara A, Lehto MU. The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010. Acta Orthop. 2013;84(4):331-337. doi:10.3109/17453674.2013.810519.
Jain A, Stein BE, Skolasky RL, Jones LC, Hungerford MW. Total joint arthroplasty in patients with rheumatoid arthritis: a United States experience from 1992 through 2005. J Arthroplasty. 2012;27(6):881-888. doi:10.1016/j.arth.2011.12.027.
Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH, Sperling JW. Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. J Shoulder Elbow Surg. 2014;23(6):791-799. doi:10.1016/j.jse.2013.09.016.
Collins DN, Harryman DT, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am. 2004;86–A(11):2489-2496. doi:10.2106/00004623-200411000-00020.
Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res. 2006;448:28-32. doi:10.1097/01.blo.0000224007.25636.85.
Rozing PM, Nagels J, Rozing MP. Prognostic factors in arthroplasty in the rheumatoid shoulder. HSS J. 2011;7(1):29-36. doi:10.1007/s11420-010-9172-1.
Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg. 2007;16(6):683-690. doi:10.1016/j.jse.2007.02.135.
Khan A, Bunker TD, Kitson JB. Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study. J Bone Joint Surg Br. 2009;91(12):1594-1600. doi:10.1302/0301-620X.91B12.22139.
Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88(8):1742-1747. doi:10.2106/JBJS.E.00851.
Gee ECA, Hanson EK, Saithna A. Reverse shoulder arthroplasty in rheumatoid arthritis: A systematic review. Open Orthop J. 2015;9:237-245. doi:10.2174/1874325001509010237.
Holcomb JO, Hebert DJ, Mighell MA, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg. 2010;19(7):1076-1084. doi:10.1016/j.jse.2009.11.049.
Postacchini R, Carbone S, Canero G, Ripani M, Postacchini F. Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review. Int Orthop. 2016;40(5):965-973. doi:10.1007/s00264-015-2916-2.
Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg. 2001;10(1):17-22. doi:10.1067/mse.2001.110515.
American Medical Association. American Medical Association Web site. www.ama-assn.org/ama. Accessed January 15, 2016.
Smith AM, Sperling JW, Cofield RH. Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg. 2005;87(8):1782-1787. doi:10.2106/JBJS.D.02452.
Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br. 2009;91(9):1197-1200. doi:10.1302/0301-620X.91B9.22035.
Geervliet PC, Somford MP, Winia P, van den Bekerom MP. Long-term results of shoulder hemiarthroplasty in patients with rheumatoid arthritis. Orthopedics. 2015;38(1):e38-e42. doi:10.3928/01477447-20150105-58.
Hettrich CM, Weldon E III, Boorman RS, Parsons M IV, Matsen FA III. Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg. 2004;86–A(7):1446-1451.
Yazdany J, Dudley RA, Chen R, Lin GA, Tseng CW. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-1480. doi:10.1002/art.39079.
Jauregui JJ, Kapadia BH, Dixit A, et al. Thirty-day complications in rheumatoid patients following total knee arthroplasty. Clin Rheumatol. 2016;35(3):595-600. doi:10.1007/s10067-015-3037-4.
Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br. 2002;84(8):1121-1125. doi:10.1302/0301-620X.84B8.0841121

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Author and Disclosure Information

The authors report no actual or potential conflict of interest in relation to this article.

Dr. Leroux is an Assistant Professor, University of Toronto, Toronto, Ontario. Dr. Basques and Dr. Saltzman are Residents, Dr. Nicholson and Dr. Romeo are Professors, and Dr. Verma is an Assistant Professor, Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois.

Address correspondence to: Bryan M. Saltzman, MD, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612 (tel, 312-243-4244; fax, 312-942-1517; email, bryan.m.saltzman@gmail.com).

Timothy S. Leroux, MD Bryce A. Basques, MD Bryan M. Saltzman, MD Gregory P. Nicholson, MD Anthony A. Romeo, MD Nikhil N. Verma, MD . Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost. Am J Orthop. June 19, 2018

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Original Research

Author(s)

Timothy S. Leroux, MD

Bryce A. Basques, MD

Bryan M. Saltzman, MD

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

Author(s)

Timothy S. Leroux, MD

Bryce A. Basques, MD

Bryan M. Saltzman, MD

Gregory P. Nicholson, MD

Anthony A. Romeo, MD

Nikhil N. Verma, MD

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ABSTRACT

Continue to: It has been suggested...

METHODS

Appendix A. ICD-9-CM Codes Corresponding to Postoperative Adverse Events

Event	*ICD-9-CM*
Acute kidney injury	584.5-584.9
Cardiac arrest	427.41, 427.5
Thromboembolic event	453.2-453.4, 453.82-453.86, 415.1
Myocardial Infarction	410.00-410.92
Peripheral nerve injury	953.0-953.9 954.0-954.9, 955.0-955.9, 956.0-956.9
Pneumonia	480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 484.1-484.8, 485, 486
Sepsis	038.0-038.9, 112.5, 785.52, 995.91, 995.92
Stroke	430, 432, 433.01-434.91, 997.02
Surgical site infection	998.51, 998.59, 996.67
Urinary tract infection	599
Wound dehiscence	998.30-998.33

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESULTS

Table 2. The Annual Utilization of Shoulder Arthroplasty Among Patients with a Diagnosis of Rheumatoid Arthritis.

Proportion of RA patients
Year	Overall Rate of Shoulder Arthroplasty^a	HA	Anatomic TSA	Reverse TSA
2002	0.39	0.23	0.16	0
2003	0.37	0.19	0.18	0
2004	0.46	0.25	0.21	0
2005	0.46	0.21	0.25	0
2006	0.47	0.20	0.27	0
2007	0.55	0.22	0.33	0
2008	0.47	0.17	0.30	0
2009	0.50	0.15	0.35	0
2010	0.58	0.15	0.37	0.06
2011	0.58	0.12	0.23	0.23
Absolute number of RA patients
2002	1295	768	527	0
2003	1247	650	597	0
2004	1667	906	761	0
2005	1722	776	946	0
2006	1847	794	1053	0
2007	2249	910	1339	0
2008	2194	799	1395	0
2009	2407	724	1683	0
2010	2869	722	1857	290
2011	3193	649	1261	1283

^aRate determined as number of RA patients undergoing shoulder arthroplasty compared to the number of patients with an RA diagnosis in the stated calendar year.

Abbreviations: HA, hemiarthroplasty; RA, rheumatoid arthritis; TSA, total shoulder arthroplasty.

Continue to: Among patients with RA...

Table 3. A Comparison of Early Adverse Events, Length of Stay, and Cost Between Patients With and Without Rheumatoid Arthritis (RA) Undergoing Shoulder Arthroplasty

Comparison of Early Adverse Event Rates
	Non-RA Patients	RA Patients	Multivariate Logistic Regression
	Non-RA Patients	RA Patients	Odds Ratio	P-Value
Overall adverse event rate	3.02%	3.12%	1.0	0.83
Specific adverse event rate
Death	0.08%	0.05%	0.9	0.91
Acute kidney injury	0.85%	0.66%	0.9	0.59
Cardiac arrest	0.05%	0.05%	1.3	0.70
Thromboembolic event	0.01%	0.00%	-	-
Myocardial Infarction	0.22%	0.06%	0.4	0.17
Peripheral nerve injury	0.08%	0.11%	1.5	0.45
Pneumonia	0.47%	0.38%	0.9	0.70
Sepsis	0.08%	0.08%	1.3	0.62
Stroke	0.07%	0.05%	0.9	0.93
Surgical site infection	0.09%	0.13%	1.4	0.52
Urinary tract infection	1.44%	1.80%	1.1	0.46
Wound dehiscence	0.01%	0.05%	3.6	0.09
Comparison of Length of Stay and Hospital Charges
	Non-RA Patients (percent)	RA Patients (percent)	Multivariate Linear Regression
	Non-RA Patients (percent)	RA Patients (percent)	Beta	P-Value
Length of stay^a	2.3±2.0	2.4±1.6	+0.1	0.002
Hospitalization cost^b	14,826±8,336	14,787±7,625	+93	0.59

^aReported in days. ^bReported in 2011 US dollars, adjusted for inflation.

DISCUSSION

Continue to: In this study, we observed...

CONCLUSION

ABSTRACT

Continue to: It has been suggested...

METHODS

Appendix A. ICD-9-CM Codes Corresponding to Postoperative Adverse Events

Event	*ICD-9-CM*
Acute kidney injury	584.5-584.9
Cardiac arrest	427.41, 427.5
Thromboembolic event	453.2-453.4, 453.82-453.86, 415.1
Myocardial Infarction	410.00-410.92
Peripheral nerve injury	953.0-953.9 954.0-954.9, 955.0-955.9, 956.0-956.9
Pneumonia	480.0-480.9, 481, 482.0-482.9, 483.0-483.8, 484.1-484.8, 485, 486
Sepsis	038.0-038.9, 112.5, 785.52, 995.91, 995.92
Stroke	430, 432, 433.01-434.91, 997.02
Surgical site infection	998.51, 998.59, 996.67
Urinary tract infection	599
Wound dehiscence	998.30-998.33

Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification

Continue to: Statistical analysis...

STATISTICAL ANALYSIS

RESULTS

Table 2. The Annual Utilization of Shoulder Arthroplasty Among Patients with a Diagnosis of Rheumatoid Arthritis.

Proportion of RA patients
Year	Overall Rate of Shoulder Arthroplasty^a	HA	Anatomic TSA	Reverse TSA
2002	0.39	0.23	0.16	0
2003	0.37	0.19	0.18	0
2004	0.46	0.25	0.21	0
2005	0.46	0.21	0.25	0
2006	0.47	0.20	0.27	0
2007	0.55	0.22	0.33	0
2008	0.47	0.17	0.30	0
2009	0.50	0.15	0.35	0
2010	0.58	0.15	0.37	0.06
2011	0.58	0.12	0.23	0.23
Absolute number of RA patients
2002	1295	768	527	0
2003	1247	650	597	0
2004	1667	906	761	0
2005	1722	776	946	0
2006	1847	794	1053	0
2007	2249	910	1339	0
2008	2194	799	1395	0
2009	2407	724	1683	0
2010	2869	722	1857	290
2011	3193	649	1261	1283

^aRate determined as number of RA patients undergoing shoulder arthroplasty compared to the number of patients with an RA diagnosis in the stated calendar year.

Abbreviations: HA, hemiarthroplasty; RA, rheumatoid arthritis; TSA, total shoulder arthroplasty.

Continue to: Among patients with RA...

Table 3. A Comparison of Early Adverse Events, Length of Stay, and Cost Between Patients With and Without Rheumatoid Arthritis (RA) Undergoing Shoulder Arthroplasty

Comparison of Early Adverse Event Rates
	Non-RA Patients	RA Patients	Multivariate Logistic Regression
	Non-RA Patients	RA Patients	Odds Ratio	P-Value
Overall adverse event rate	3.02%	3.12%	1.0	0.83
Specific adverse event rate
Death	0.08%	0.05%	0.9	0.91
Acute kidney injury	0.85%	0.66%	0.9	0.59
Cardiac arrest	0.05%	0.05%	1.3	0.70
Thromboembolic event	0.01%	0.00%	-	-
Myocardial Infarction	0.22%	0.06%	0.4	0.17
Peripheral nerve injury	0.08%	0.11%	1.5	0.45
Pneumonia	0.47%	0.38%	0.9	0.70
Sepsis	0.08%	0.08%	1.3	0.62
Stroke	0.07%	0.05%	0.9	0.93
Surgical site infection	0.09%	0.13%	1.4	0.52
Urinary tract infection	1.44%	1.80%	1.1	0.46
Wound dehiscence	0.01%	0.05%	3.6	0.09
Comparison of Length of Stay and Hospital Charges
	Non-RA Patients (percent)	RA Patients (percent)	Multivariate Linear Regression
	Non-RA Patients (percent)	RA Patients (percent)	Beta	P-Value
Length of stay^a	2.3±2.0	2.4±1.6	+0.1	0.002
Hospitalization cost^b	14,826±8,336	14,787±7,625	+93	0.59

^aReported in days. ^bReported in 2011 US dollars, adjusted for inflation.

DISCUSSION

Continue to: In this study, we observed...

CONCLUSION

References

Mertelsmann-Voss C, Lyman S, Pan TJ, Goodman SM, Figgie MP, Mandl LA. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014;66(6):1432-1439. doi:10.1002/art.38384.
Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis. 2010;69(5):868-871. doi:10.1136/ard.2009.112474.
HCUP Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality; 2002-2011.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004.
Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109-1118. doi:10.1097/MLR.0b013e31825f64d0.
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5.
Weiss RJ, Ehlin A, Montgomery SM, Wick MC, Stark A, Wretenberg P. Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatol Oxf. 2008 ;47(4):491-494. doi. 10.1093/rheumatology/ken009.
Jämsen E, Virta LJ, Hakala M, Kauppi MJ, Malmivaara A, Lehto MU. The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010. Acta Orthop. 2013;84(4):331-337. doi:10.3109/17453674.2013.810519.
Jain A, Stein BE, Skolasky RL, Jones LC, Hungerford MW. Total joint arthroplasty in patients with rheumatoid arthritis: a United States experience from 1992 through 2005. J Arthroplasty. 2012;27(6):881-888. doi:10.1016/j.arth.2011.12.027.
Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH, Sperling JW. Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. J Shoulder Elbow Surg. 2014;23(6):791-799. doi:10.1016/j.jse.2013.09.016.
Collins DN, Harryman DT, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am. 2004;86–A(11):2489-2496. doi:10.2106/00004623-200411000-00020.
Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res. 2006;448:28-32. doi:10.1097/01.blo.0000224007.25636.85.
Rozing PM, Nagels J, Rozing MP. Prognostic factors in arthroplasty in the rheumatoid shoulder. HSS J. 2011;7(1):29-36. doi:10.1007/s11420-010-9172-1.
Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg. 2007;16(6):683-690. doi:10.1016/j.jse.2007.02.135.
Khan A, Bunker TD, Kitson JB. Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study. J Bone Joint Surg Br. 2009;91(12):1594-1600. doi:10.1302/0301-620X.91B12.22139.
Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88(8):1742-1747. doi:10.2106/JBJS.E.00851.
Gee ECA, Hanson EK, Saithna A. Reverse shoulder arthroplasty in rheumatoid arthritis: A systematic review. Open Orthop J. 2015;9:237-245. doi:10.2174/1874325001509010237.
Holcomb JO, Hebert DJ, Mighell MA, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg. 2010;19(7):1076-1084. doi:10.1016/j.jse.2009.11.049.
Postacchini R, Carbone S, Canero G, Ripani M, Postacchini F. Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review. Int Orthop. 2016;40(5):965-973. doi:10.1007/s00264-015-2916-2.
Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg. 2001;10(1):17-22. doi:10.1067/mse.2001.110515.
American Medical Association. American Medical Association Web site. www.ama-assn.org/ama. Accessed January 15, 2016.
Smith AM, Sperling JW, Cofield RH. Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg. 2005;87(8):1782-1787. doi:10.2106/JBJS.D.02452.
Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br. 2009;91(9):1197-1200. doi:10.1302/0301-620X.91B9.22035.
Geervliet PC, Somford MP, Winia P, van den Bekerom MP. Long-term results of shoulder hemiarthroplasty in patients with rheumatoid arthritis. Orthopedics. 2015;38(1):e38-e42. doi:10.3928/01477447-20150105-58.
Hettrich CM, Weldon E III, Boorman RS, Parsons M IV, Matsen FA III. Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg. 2004;86–A(7):1446-1451.
Yazdany J, Dudley RA, Chen R, Lin GA, Tseng CW. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-1480. doi:10.1002/art.39079.
Jauregui JJ, Kapadia BH, Dixit A, et al. Thirty-day complications in rheumatoid patients following total knee arthroplasty. Clin Rheumatol. 2016;35(3):595-600. doi:10.1007/s10067-015-3037-4.
Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br. 2002;84(8):1121-1125. doi:10.1302/0301-620X.84B8.0841121

References

Mertelsmann-Voss C, Lyman S, Pan TJ, Goodman SM, Figgie MP, Mandl LA. US trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. Arthritis Rheumatol. 2014;66(6):1432-1439. doi:10.1002/art.38384.
Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis. 2010;69(5):868-871. doi:10.1136/ard.2009.112474.
HCUP Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality; 2002-2011.
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004.
Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care. 2012;50(12):1109-1118. doi:10.1097/MLR.0b013e31825f64d0.
van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care. 2009;47(6):626-633. doi:10.1097/MLR.0b013e31819432e5.
Weiss RJ, Ehlin A, Montgomery SM, Wick MC, Stark A, Wretenberg P. Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatol Oxf. 2008 ;47(4):491-494. doi. 10.1093/rheumatology/ken009.
Jämsen E, Virta LJ, Hakala M, Kauppi MJ, Malmivaara A, Lehto MU. The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010. Acta Orthop. 2013;84(4):331-337. doi:10.3109/17453674.2013.810519.
Jain A, Stein BE, Skolasky RL, Jones LC, Hungerford MW. Total joint arthroplasty in patients with rheumatoid arthritis: a United States experience from 1992 through 2005. J Arthroplasty. 2012;27(6):881-888. doi:10.1016/j.arth.2011.12.027.
Barlow JD, Yuan BJ, Schleck CD, Harmsen WS, Cofield RH, Sperling JW. Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up. J Shoulder Elbow Surg. 2014;23(6):791-799. doi:10.1016/j.jse.2013.09.016.
Collins DN, Harryman DT, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am. 2004;86–A(11):2489-2496. doi:10.2106/00004623-200411000-00020.
Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res. 2006;448:28-32. doi:10.1097/01.blo.0000224007.25636.85.
Rozing PM, Nagels J, Rozing MP. Prognostic factors in arthroplasty in the rheumatoid shoulder. HSS J. 2011;7(1):29-36. doi:10.1007/s11420-010-9172-1.
Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg. 2007;16(6):683-690. doi:10.1016/j.jse.2007.02.135.
Khan A, Bunker TD, Kitson JB. Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study. J Bone Joint Surg Br. 2009;91(12):1594-1600. doi:10.1302/0301-620X.91B12.22139.
Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88(8):1742-1747. doi:10.2106/JBJS.E.00851.
Gee ECA, Hanson EK, Saithna A. Reverse shoulder arthroplasty in rheumatoid arthritis: A systematic review. Open Orthop J. 2015;9:237-245. doi:10.2174/1874325001509010237.
Holcomb JO, Hebert DJ, Mighell MA, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg. 2010;19(7):1076-1084. doi:10.1016/j.jse.2009.11.049.
Postacchini R, Carbone S, Canero G, Ripani M, Postacchini F. Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review. Int Orthop. 2016;40(5):965-973. doi:10.1007/s00264-015-2916-2.
Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg. 2001;10(1):17-22. doi:10.1067/mse.2001.110515.
American Medical Association. American Medical Association Web site. www.ama-assn.org/ama. Accessed January 15, 2016.
Smith AM, Sperling JW, Cofield RH. Rotator cuff repair in patients with rheumatoid arthritis. J Bone Joint Surg. 2005;87(8):1782-1787. doi:10.2106/JBJS.D.02452.
Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br. 2009;91(9):1197-1200. doi:10.1302/0301-620X.91B9.22035.
Geervliet PC, Somford MP, Winia P, van den Bekerom MP. Long-term results of shoulder hemiarthroplasty in patients with rheumatoid arthritis. Orthopedics. 2015;38(1):e38-e42. doi:10.3928/01477447-20150105-58.
Hettrich CM, Weldon E III, Boorman RS, Parsons M IV, Matsen FA III. Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg. 2004;86–A(7):1446-1451.
Yazdany J, Dudley RA, Chen R, Lin GA, Tseng CW. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-1480. doi:10.1002/art.39079.
Jauregui JJ, Kapadia BH, Dixit A, et al. Thirty-day complications in rheumatoid patients following total knee arthroplasty. Clin Rheumatol. 2016;35(3):595-600. doi:10.1007/s10067-015-3037-4.
Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br. 2002;84(8):1121-1125. doi:10.1302/0301-620X.84B8.0841121

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

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Shoulder Arthroplasty in Patients with Rheumatoid Arthritis: A Population-Based Study Examining Utilization, Adverse Events, Length of Stay, and Cost

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There was a significant increase in the utilization of shoulder arthroplasty in RA patients, particularly TSA.
There was a significant increase in the number of RA patients who underwent shoulder arthroplasty with a diagnosis of rotator cuff disease.
There were no significant differences in adverse events or mean hospitalization costs between RA and non-RA patients.
Non-RA patients had a significantly shorter length of stay.
The utilization of shoulder arthroplasty in patients with RA significantly increased from 2002 to 2011, which may partly reflect a trend toward management of rotator cuff disease with arthroplasty rather than repair.

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Management of Isolated Greater Tuberosity Fractures: A Systematic Review

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David M. Levy, MD

Brandon J. Erickson, MD

Joshua D. Harris, MD

Bernard R. Bach Jr, MD

Nikhil N. Verma, MD

Anthony A. Romeo, MD

Take-Home Points

Fractures of the greater tuberosity are often mismanaged.
Comprehension of greater tuberosity fractures involves classification into nonoperative and operative treatment, displacement >5mm or <5 mm, and open vs arthroscopic surgery.
Nearly a third of patients may suffer concomitant anterior glenohumeral instability.
Stiffness is the most common postoperative complication.
Surgery is associated with high patient satisfaction and low rates of complications and reoperations.

Although proximal humerus fractures are common in the elderly, isolated fractures of the greater tuberosity occur less often. Management depends on several factors, including fracture pattern and displacement.^1,2 Nondisplaced fractures are often successfully managed with sling immobilization and early range of motion.^3,4 Although surgical intervention improves outcomes in displaced greater tuberosity fractures, the ideal surgical treatment is less clear.⁵

Displaced greater tuberosity fractures may require surgery for prevention of subacromial impingement and range-of-motion deficits.² Superior fracture displacement results in decreased shoulder abduction, and posterior displacement can limit external rotation.⁶Although the greater tuberosity can displace in any direction, posterosuperior displacement has the worst outcomes.¹ The exact surgery-warranting displacement amount ranges from 3 mm to 10 mm but is yet to be clearly elucidated.^5,6 Less displacement is tolerated by young overhead athletes, and more displacement by older less active patients.^5,7,8Surgical options for isolated greater tuberosity fractures include fragment excision, open reduction and internal fixation (ORIF), closed reduction with percutaneous fixation, and arthroscopically assisted reduction with internal fixation.^3,9,10

We conducted a study to determine the management patterns for isolated greater tuberosity fractures. We hypothesized that greater tuberosity fractures displaced <5 mm may be managed nonoperatively and that greater tuberosity fractures displaced >5 mm require surgical fixation.

Methods

Search Strategy

We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist¹¹ and registered it (CRD42014010691) with the PROSPERO international prospective register of systematic reviews. Literature searches using the PubMed/Medline database and the Cochrane Central Register of Clinical Trials were completed in August 2014. There were no date or year restrictions. Key words were used to capture all English- language studies with level I to IV evidence (Oxford Centre for Evidence-Based Medicine) and reported clinical or radiographic outcomes. Initial exclusion criteria were cadaveric, biomechanical, histologic, and kinematic results. An electronic search algorithm with key words and a series of NOT phrases was designed to match our exclusion criteria:

((((((((((((((((((((((((((((((((((((((((((((((((((greater[Title/Abstract]) AND tuberosity [Title/Abstract] OR tubercle [Title/Abstract]) AND fracture[Title/Abstract]) AND proximal[Title/Abstract] AND (English[lang]))) NOT intramedullary[Title] AND (English[lang]))) NOT nonunion[Title] AND (English[lang]))) NOT malunion[Title] AND (English[lang]))) NOT biomechanical[Title/Abstract] AND (English[lang]))) NOT cadaveric[Title/Abstract] AND (English[lang]))) NOT cadaver[Title/Abstract] AND (English[lang]))) NOT ((basic[Title/Abstract]) AND science[Title/Abstract] AND (English[lang])) AND (English[lang]))) NOT revision[Title] AND (English[lang]))) NOT pediatric[Title] AND (English[lang]))) NOT physeal[Title] AND (English[lang]))) NOT children[Title] AND (English[lang]))) NOT instability[Title] AND (English[lang]))) NOT imaging[Title])) NOT salter[Title])) NOT physis[Title])) NOT shaft[Title])) NOT distal[Title])) NOT clavicle[Title])) NOT scapula[Title])) NOT ((diaphysis[Title]) AND diaphyseal[Title]))) NOT infection[Title])) NOT laboratory[Title/Abstract])) NOT metastatic[Title/Abstract])) NOT (((((((malignancy[Title/Abstract]) OR malignant[Title/Abstract]) OR tumor[Title/Abstract]) OR oncologic[Title/Abstract]) OR cyst[Title/Abstract]) OR aneurysmal[Title/Abstract]) OR unicameral[Title/Abstract]).

Study Selection

We obtained 135 search results and reviewed them for further differentiation. All the references in these studies were cross-referenced for inclusion (if missed by the initial search), which added another 15 studies. Technical notes, letters to the editor, and level V evidence reviews were excluded. Double-counting of patients was avoided by comparing each study’s authors, data collection period, and ethnic population with those of the other studies. In cases of overlapping authorship, period, or place, only the study with the longer follow-up, more patients, or more comprehensive data was included. For studies separating outcomes by diagnosis, only outcomes of isolated greater tuberosity fractures were included. Data on 3- or 4-part proximal humerus fractures and isolated lesser tuberosity fractures were excluded. Studies that could not be deconstructed as such or that were devoted solely to one of our exclusion criteria were excluded. Minimum follow-up was 2 years. After all inclusion and exclusion criteria were accounted for, 13 studies with 429 patients (429 shoulders) were selected for inclusion (Figure, Table 1).^2,5,12-22

Data Extraction

We extracted data from the 13 studies that met the eligibility criteria. Details of study design, sample size, and patient demographics, including age, sex, and hand dominance, were recorded, as were mechanism of injury and concomitant anterior shoulder instability. To capture the most patients, we noted radiographic fracture displacement categorically rather than continuously; patients were divided into 2 displacement groups (<5 mm, >5 mm). Most studies did not define degree of comminution or specific direction of displacement per fracture, so these variables were not included in the data analysis. Nonoperative management and operative management were studied. We abstracted surgical factors, such as approach, method, fixation type (screws or sutures), and technique (suture anchors or transosseous tunnels). Clinical outcomes included physical examination findings, functional assessment results (patient satisfaction; Constant and University of California Los Angeles [UCLA] shoulder scores), and the number of revisions. Radiologic outcomes, retrieved from radiographs or computed tomography scans, focused on loss of reduction (as determined by the respective authors), malunion, nonunion, and heterotopic ossification. Each study’s methodologic quality and bias were evaluated with the 15-item Modified Coleman Methodology Score (MCMS), which was described by Cowan and colleagues.²³ The MCMS has been used to assess randomized and nonrandomized patient trials.^24,25 Its scaled potential score ranges from 0 to 100 (85-100, excellent; 70-84, good; 55-69, fair; <55, poor).

Statistical Analysis

We report our data as weighted means (SDs). A mean was calculated for each study that reported a respective data point, and each mean was then weighed according to its study sample size. This calculation was performed by multiplying a study’s individual mean by the number of patients enrolled in that study and dividing the sum of these weighted data points by the number of eligible patients in all relevant studies. The result was that the nonweighted means from studies with smaller sample sizes did not carry as much weight as the nonweighted means from larger studies. We compared 3 paired groups: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic). Regarding all patient, surgery, and outcomes data, unpaired Student t tests were used for continuous variables and 2-tailed Fisher exact tests for categorical variables with α = 0.05 (SPSS Version 18; IBM).

Results

Demographic information and treatment strategies are listed in Table 2. Fifty-eight percent of patients were male, 59.0% of dominant shoulders were affected, and 59.2% of fractures were displaced <5 mm. Concomitant shoulder instability was reported in 28.1% of patients. Mechanism of injury was not reported in all studies but most commonly (n = 75; 49.3%) involved a fall on an outstretched hand; 31 patients (20.4%) had a sports-related injury, and another 37 (24.3%) were injured in a motor vehicle collision. Of the 429 patients, 217 (50.6%) were treated nonoperatively, and 212 (49.4%) underwent surgery. Open, arthroscopic, and percutaneous approaches were reported. No studies presented outcomes of fragment excision.

Postoperative physical examination findings were underreported so that surgical groups could be compared. Of all the surgical studies, 4 reported postoperative forward elevation (mean, 160°; SD, 9.8°) and external rotation (mean, 46.4°; SD 26.3°).^14,15,18,22No malunions and only 1 nonunion were reported in all 13 studies. No deaths or other serious medical complications were reported. Patients with anterior instability more often underwent surgery than were treated nonoperatively (39.2% vs 12.0%; P < .01) and more often had fractures displaced >5 mm than <5 mm (44.3% vs 14.5%; P < .01).

Comparisons of treatment type are listed in Table 3. Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (P < .01) and better patient satisfaction (P < .01). Operative patients had a significantly higher rate of shoulder stiffness (P < .01). Eight operative patients (3.8%) and no nonoperative patients required reoperation during clinical follow-up (P < .01). All 12 reported cases of stiffness were in the operative group, and 3 required revision surgery. One patient required revision ORIF. There were 2 cases of postoperative superficial infection (0.9%) and 4 neurologic injuries (1.9%).

Comparisons of displacement amount are listed in Table 4. Compared with fractures displaced >5 mm, those displaced <5 mm had more radiographic losses of reduction (P < .01) but fewer instances of heterotopic ossification (P < .01). Fractures displaced >5 mm were significantly more likely than not to be managed with surgery (P < .01) and significantly more likely to develop stiffness after treatment (P = .01). One patient (0.4%) with a fracture displaced <5 mm eventually underwent surgery for stiffness, and 6 patients (3.6%) with fractures displaced >5 mm required reoperation (P = .02).

Comparisons of surgery type are listed in Table 5. All open procedures were performed with a deltoid-splitting approach. Screw fixation was used in 4 cases: 2 percutaneous^5,21and 2 open.^2,5 The other open and arthroscopic studies described suture fixation, half with anchors (77/156 patients; 49.4%) and half with transosseous tunnels (79/156; 50.6%). There were no statistically significant differences between open/percutaneous and arthroscopic techniques in terms of stiffness, superficial infection, neurologic injury, or reoperation rate.

Fisher exact tests were used to perform isolated comparisons of screws and sutures as well as suture anchors and transosseous tunnels. Patients with screw fixation were significantly (P = .051) less likely to require reoperation (0/56; 0%) than patients with suture fixation (8/100; 8.0%). Screw fixation also led to significantly less stiffness (0% vs 12.0%; P < .01) but trended toward a higher rate of superficial infection (3.6% vs 0%; P = .13). There was no statistical difference in nerve injury rates between screws and sutures (1.8% vs 3.0%; P = 1.0). There were no significant differences in reoperations, stiffness, superficial infections, or nerve injuries between suture anchor and transosseous tunnel constructs.

For all 13 studies, mean (SD) MCMS was 41.1 (8.6).

Discussion

Five percent of all fractures involve the proximal humerus, and 20% of proximal humerus fractures are isolated greater tuberosity fractures.^26,27 In his classic 1970 article, Neer⁶ formulated the 4-part proximal humerus fracture classification and defined greater tuberosity fracture “parts” using the same criteria as for other fracture “parts.” Neer⁶ recommended nonoperative management for isolated greater tuberosity fractures displaced <1 cm but did not present evidence corroborating his recommendation. More recent cutoffs for nonoperative management include 5 mm (general population) and 3 mm (athletes).^7,17

In the present systematic review of greater tuberosity fractures, 3 separate comparisons were made: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic).

Treatment Type. Only 4 studies reported data on nonoperative treatment outcomes.^5,12,16,17 Of these 4 studies, 2 found successful outcomes for fractures displaced <5 mm.^12,17Platzer and colleagues¹⁷ found good or excellent results in 97% of 135 shoulders after 4 years. Good results were defined with shoulder scores of ≥80 (Constant), <8 (Vienna), and >28 (UCLA), and excellent results were defined with maximum scores on 2 of the 3 systems. Platzer and colleagues¹⁷ also found nonsignificantly worse shoulder scores with superior displacement of 3 mm to 5 mm and recommended surgery for overhead athletes in this group. Rath and colleagues¹² described a successful 3-phase rehabilitation protocol of sling immobilization for 3 weeks, pendulum exercises for 3 weeks, and active exercises thereafter. By an average of 31 months, patient satisfaction scores improved to 9.5 from 4.2 (10-point scale), though the authors cautioned that pain and decreased motion lasted 8 months on average. Conservative treatment was far less successful in the 2 studies of fractures displaced >5 mm.^5,16 Keene and colleagues¹⁶ reported unsatisfactory results in all 4 patients with fractures displaced >1.5 cm. In a study separate from their 2005 analysis,¹⁷ Platzer and colleagues⁵in 2008 evaluated displaced fractures and found function and patient satisfaction were inferior after nonoperative treatment than after surgery. The studies by Keene and colleagues¹⁶and Platzer and colleagues⁵ support the finding of an overall lower patient satisfaction rate in nonoperative patients.

Fracture Displacement Amount. Only 2 arthroscopic studies and no open studies addressed surgery for fractures displaced <5 mm. Fewer than 16% of these fractures were managed operatively, and <1% required reoperation. By contrast, almost all fractures displaced >5 mm were managed operatively, and 3.6% required reoperation. Radiographic loss of reduction was more common in fractures displaced <5 mm, primarily because they were managed without fixation. Radiographic loss of reduction was reported in only 9 operatively treated patients, none of whom was symptomatic enough to require another surgery.⁵Reoperations were most commonly performed for stiffness, which itself was significantly more common in fractures displaced >5 mm. Bhatia and colleagues¹⁴ reported the highest reoperation rate (14.3%; 3/21), but they studied more complex, comminuted fractures of the greater tuberosity. Two of their 3 reoperations were biceps tenodeses for inflamed, stiff tenosynovitis, and the third patient had a foreign body giant cell reaction to suture material. Fewer than 1% of patients with operatively managed displaced fractures required revision ORIF, and <2% developed a superficial infection or postoperative nerve palsy.^19,22 For displaced greater tuberosity fractures, surgery is highly successful overall, complication rates are very low, and 90% of patients report being satisfied.

Surgery Type. Patients were divided into 2 groups. In the nonarthroscopic group, open and percutaneous approaches were used. All studies that described a percutaneous approach used screw fixation^5,21; in addition, 32 patients were treated with screws through an open approach.^2,5 The other open and arthroscopic studies used suture fixation. Interestingly, no studies reported on clinical outcomes of fragment excision. There were no statistically significant differences in rates of reoperation, stiffness, infection, or neurologic injury between the arthroscopic and nonarthroscopic groups. Patient satisfaction scores were slightly higher in the nonarthroscopic group (91.0% vs 87.8%), but the difference was not statistically significant.

With surgical techniques isolated, there were no significant differences between suture anchors and transosseous tunnel constructs, but screws performed significantly better than suture techniques. Compared with suture fixation, screw fixation led to significantly fewer cases of stiffness and reoperation, which suggests surgeons need to give screws more consideration in the operative management of these fractures. However, the number of patients treated with screws was smaller than the number treated with suture fixation; it is possible the differences between these cohorts would be eliminated if there were more patients in the screw cohort. In addition, screw fixation was universally performed with an open or percutaneous approach and trended toward a higher infection rate. As screw and suture techniques have low rates of complications and reoperations, we recommend leaving fixation choice to the surgeon.

Anterior shoulder instability has been associated with greater tuberosity fractures.^1,8,19 The supraspinatus, infraspinatus, and teres minor muscles all insert into the greater tuberosity and resist anterior translation of the proximal humerus. Loss of this dynamic muscle stabilization is amplified by tuberosity fracture displacement: Anterior shoulder instability was significantly more common in fractures displaced >5 mm (44.3%) vs <5 mm (14.5%). In turn, glenohumeral instability was more common in patients treated with surgery, specifically open surgery, because displaced fractures may not be as easily accessed with arthroscopic techniques. No studies reported concomitant labral repair or capsular plication techniques.

This systematic review was limited by the studies analyzed. All but 1 study⁵ had level IV evidence. Mean (SD) MCMS was 41.8 (8.6). Any MCMS score <54 indicates a poor methodology level, but this scoring system is designed for randomized controlled trials,²³ and there were none in this study. Physical examination findings, such as range of motion, were underreported. In addition, radiographic parameters were not consistently described but rather were determined by the respective authors’ subjective interpretations of malunion, nonunion, and loss of reduction. Publication bias is present in that we excluded non- English language studies and medical conference abstracts and may have omitted potentially eligible studies not discoverable with our search methodology. Performance bias is a factor in any systematic review with multiple surgeons and wide variation in surgical technique.

Conclusion

Greater tuberosity fractures displaced <5 mm may be safely managed nonoperatively, as there are no reports of nonoperatively managed fractures that subsequently required surgery. Nonoperative treatment was initially associated with low patient satisfaction, but only because displaced fractures were conservatively managed in early studies.^5,16 Fractures displaced >5 mm respond well to operative fixation with screws, suture anchors, or transosseous suture tunnels. Stiffness is the most common postoperative complication (<6%), followed by heterotopic ossification, transient neurapraxias, and superficial infection. There are no discernible differences in outcome between open and arthroscopic techniques, but screw fixation may lead to significantly fewer cases of stiffness and reoperation in comparison with suture constructs.

References

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2. Yin B, Moen TC, Thompson SA, Bigliani LU, Ahmad CS, Levine WN. Operative treatment of isolated greater tuberosity fractures: retrospective review of clinical and functional outcomes. Orthopedics. 2012;35(6):e807-e814.

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5. Platzer P, Thalhammer G, Oberleitner G, et al. Displaced fractures of the greater tuberosity: a comparison of operative and nonoperative treatment. J Trauma. 2008;65(4):843-848.

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8. McLaughlin HL. Dislocation of the shoulder with tuberosity fracture. Surg Clin North Am. 1963;43:1615-1620.

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Authors’ Disclosure Statement: Dr. Harris reports that he serves as a board or committee member for the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy, Arthroscopy Association of North America, and Frontiers in Surgery; he has received research support from DePuy Synthes and Smith & Nephew, royalties from SLACK Incorporated, and is paid by NIA Magellan, Ossur, and Smith & Nephew. Dr. Bach reports that he has received research support from Arthrex, Inc., CONMED Linvatec, DJ Orthopaedics, Ossur, Smith & Nephew, and Tornier as well as royalties from SLACK Incorporated. Dr. Verma reports that he serves as a board or committee member for the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association Learning Center Committee, Journal of Knee Surgery, and SLACK Incorporated; he has received research support from Arthrex, Inc., Arthrosurface, DJ Orthopaedics, Smith & Nephew, Athletico, ConMed Linvatec, Miomed, and Mitek; he has received publishing royalties, financial, or material support from Arthroscopy and Vindico Medical-Orthopedics Hyperguide; he has received stock or stock options from Cymedica, Minivasive, and Omeros and serves as a paid consultant for Orthospace and Smith & Nephew. Dr. Romeo reports that he serves as a board or committee member for the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Orthopedics, Orthopedics Today, SAGE, and Wolters Kluwer Health—Lippincott Williams & Wilkins; he has received research support from Aesculap/B.Braun, Arthrex, Inc., Histogenics, Medipost, NuTech, Orthospace, Smith & Nephew, and Zimmer Biomet; he has received other financial or material support from AANA, Arthrex, Inc., and Major League Baseball; he has received publishing royalties, financial and/or material support from Saunders/Mosby-Elsevier and SLACK Incorporated. The other authors report no actual or potential conflict of interest in relation to this article.

Issue

The American Journal of Orthopedics - 46(6)

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The American Journal of Orthopedics

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E445-E453

Read more about Management of Isolated Greater Tuberosity Fractures: A Systematic Review

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Original Research

Author(s)

David M. Levy, MD

Brandon J. Erickson, MD

Joshua D. Harris, MD

Bernard R. Bach Jr, MD

Nikhil N. Verma, MD

Anthony A. Romeo, MD

Author(s)

David M. Levy, MD

Brandon J. Erickson, MD

Joshua D. Harris, MD

Bernard R. Bach Jr, MD

Nikhil N. Verma, MD

Anthony A. Romeo, MD

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Article PDF

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Take-Home Points

Fractures of the greater tuberosity are often mismanaged.
Comprehension of greater tuberosity fractures involves classification into nonoperative and operative treatment, displacement >5mm or <5 mm, and open vs arthroscopic surgery.
Nearly a third of patients may suffer concomitant anterior glenohumeral instability.
Stiffness is the most common postoperative complication.
Surgery is associated with high patient satisfaction and low rates of complications and reoperations.

Methods

Search Strategy

Study Selection

Data Extraction

Statistical Analysis

Results

For all 13 studies, mean (SD) MCMS was 41.1 (8.6).

Discussion

Conclusion

Take-Home Points

Fractures of the greater tuberosity are often mismanaged.
Comprehension of greater tuberosity fractures involves classification into nonoperative and operative treatment, displacement >5mm or <5 mm, and open vs arthroscopic surgery.
Nearly a third of patients may suffer concomitant anterior glenohumeral instability.
Stiffness is the most common postoperative complication.
Surgery is associated with high patient satisfaction and low rates of complications and reoperations.