Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England

Abstract

ObjectivesTo answer a national research priority by comparing the risk-benefit and costs associated with reverse total shoulder replacement (RTSR) and anatomical total shoulder replacement (TSR) in patients having elective primary shoulder replacement for osteoarthritis.DesignPopulation based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England.SettingPublic hospitals and publicly funded procedures at private hospitals in England, 2012-20.ParticipantsAdults aged 60 years or older who underwent RTSR or TSR for osteoarthritis with intact rotator cuff tendons. Patients were identified from the National Joint Registry and linked to NHS Hospital Episode Statistics and civil registration mortality data. Propensity score matching and inverse probability of treatment weighting were used to balance the study groups.Main outcome measuresThe main outcome measure was revision surgery. Secondary outcome measures included serious adverse events within 90 days, reoperations within 12 months, prolonged hospital stay (more than three nights), change in Oxford Shoulder Score (preoperative to six month postoperative), and lifetime costs to the healthcare service.ResultsThe propensity score matched population comprised 7124 RTSR or TSR procedures (126 were revised), and the inverse probability of treatment weighted population comprised 12 968 procedures (294 were revised) with a maximum follow-up of 8.75 years. RTSR had a reduced hazard ratio of revision in the first three years (hazard ratio local minimum 0.33, 95% confidence interval 0.18 to 0.59) with no clinically important difference in revision-free restricted mean survival time, and a reduced relative risk of reoperations at 12 months (odds ratio 0.45, 95% confidence interval 0.25 to 0.83) with an absolute risk difference of −0.51% (95% confidence interval −0.89 to −0.13). Serious adverse events and prolonged hospital stay risks, change in Oxford Shoulder Score, and modelled mean lifetime costs were similar. Outcomes remained consistent after weighting.ConclusionsThis study’s findings provide reassurance that RTSR is an acceptable alternative to TSR for patients aged 60 years or older with osteoarthritis and intact rotator cuff tendons. Despite a significant difference in the risk profiles of revision surgery over time, no statistically significant and clinically important differences between RTSR and TSR were found in terms of long term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.

Choosing the best shoulder replacement

“…Valsamis and colleagues should be commended on a comprehensive exploration of available data. Their main finding was no clinically important difference in long term revision surgery between these two implant types 2. No differences were identified for any other secondary outcomes, including reoperations within 12 months of surgery serious adverse events within 90 days or prolonged hospital stay.…”

“…This trial commenced in 2022, but will not report its results until the spring of 2027 at the earliest 1. In a linked paper in The BMJ (doi:10.1136/bmj-2023-077939), Valsamis and colleagues leveraged routinely collected data from public and private hospitals in England, using modern epidemiological methods to provide faster high quality evidence to answer this important question 2. By combining data from the National Joint Registry and NHS Hospital Episode Statistics datasets, they harnessed one of the world’s largest and most comprehensive repositories of shoulder replacement information.…”