Is rTSA the Solution to Every Patient’s Problem?

Howard Routman, DO

Read the complete study: Causes of poor postoperative improvement after reverse total shoulder arthroplasty

This study reviewed comorbidities and results for higher baseline American Shoulder and Elbow Surgeons (ASES) scores that are correlated with poor post-operative improvement. The study collected data from a total of 150 patients who underwent reverse total shoulder arthroplasty (rTSA) from 2007-2013. A minimum of two-year post-operative ASES scores were included, and poor post-op improvement was defined as a change of ASES score of less than 12 points. Out of the 150 patients, male gender, presence of an intact rotator cuff at the time of surgery, depression, a higher baseline ASES score and higher total number of medical comorbidities were associated with poor post-operative improvement after rTSA. Neither patient age, nor indication for surgery, was found to correlate with poor improvement after rTSA. In general, the study population was older, with an average age of 71.6 +/- 8.8, and the majority of patients were female.

Literature Review:

It should be noted that as the number of rTSAs continues to grow rapidly—due to its success in improving pain and function in most patients—some patients fail to improve clinically. Interestingly, the article also mentioned that patient satisfaction is now frequently linked to hospital and physician reimbursements. This study emphasizes reasons for poor post-operative improvement throughout with baseline pulled  from ASES scores and patient data. Physical examination findings were not a focused component of the analysis.

The temptation to view the rTSA as a panacea that can fix everything is high.  We need to temper our enthusiasm and ensure that we select our patients wisely.

When managing expectations with higher pre-operative ASES scores, I don’t really look at an ASES score pre-operatively as a screening tool, but I appreciate the concept of the ‘delta’ of improvement before surgery.  If a patient’s radiograph shows a classic cuff tear arthropathy, and the patient has maintained overhead elevation and mild pain, the change in function and pain that can be provided with a perfect reverse is minimal.  Ideally, patient selection can help us identify who best benefits from rTSA.  By limiting the indications to patients who cannot elevate beyond 90⁰, and who identify themselves has having quality-of-life-altering pain, we can skew our delta favorably.  The article referenced a study by Wall et al that noted patients who underwent rTSA for primary osteoarthritis had much smaller improvements in range of motion compared with patients who underwent rTSA for rotator cuff tear arthropathy or massive tears. Current expectations for improving post-operative function versus outcomes in patients with high levels of pre-operative function are to be noted.

In a cohort of 31 of my rTSA patients, the average post op ASES score was 82.68 (+/- 18.4), compared to 76 +/- 16.7 as mentioned in the study. Of the 31 patients, 18 had both pre-op and post-op ASES scores and had an average of 46.6 improvement in ASES. Only one had improvement of less than 12.  Seventeen of the 31 had an intact rotator cuff in the post-op diagnosis, compared to 34 of 150 with intact rotator cuff from this study. Twenty three percent of my patients were male, compared to 32 percent from study. The average age of my patients is 73 +-7.3, compared to 71.6 +/- 8.8 from study, with a BMI of 28.1 +- 5.83, which was almost identical to the patients in the study. (Table 1)

Table 1. Dr. Routman’s rTSA Patient Outcomes vs. Outcomes Cited in the Study

  Dr. Routman Study
Patient cohort 31 150
Patients with poor post-operative improvement (change in ASES score of less than 12) 1 20
Average improvement in ASES score 46.6 46.8
Patients with intact rotator cuff 17 of 31 34 of 150
Patient gender 23 percent male 32 percent male
Patient age 73 +-7.3 71.6 +/- 8.8
Patient BMI 28.1 +- 5.83 28.4 +/- 6.3

I agree with the author that rTSA is a great solution to many problems, but care needs to be taken when considering a reverse in cuff-intact male patients.  These patients remain good anatomic arthroplasty candidates up through their 70s, if the glenoid is manageable. The temptation to view the rTSA as a panacea that can fix everything is high.  We need to temper our enthusiasm and ensure that we select our patients wisely.

Howard Routman, DO is a shoulder surgeon at Atlantis Orthopaedics in Palm Beach, FL. He completed his residency at Philadelphia College of Osteopathic Medicine. He conducted his fellowship, specializing in shoulder reconstruction, at Hughston Sports Medicine Foundation. He also is the immediate past president of the Association of Clinical Elbow and Shoulder Surgeons (ACESS), is an associate member of the American Shoulder and Elbow Surgeons (ASES) and directs the Palm Beach Shoulder Service within Atlantis Orthopedics in Palm Beach County, Florida. Dr. Routman is a design team member for the Equinoxe platform fracture stem and fracture plate.