Clinical Review

Reverse Total Shoulder Arthroplasty: Indications and Techniques Across the World

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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

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