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Comparative Study
. 2024 Apr 30:385:e077939.
doi: 10.1136/bmj-2023-077939.

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

Epaminondas Markos Valsamis  1   2 , Albert Prats-Uribe  2   3 , Ian Koblbauer  2   4 , Sophie Cole  1   2 , Adrian Sayers  5 , Michael R Whitehouse  5   6 , Gillian Coward  7 , Gary S Collins  2   4 , Rafael Pinedo-Villanueva  1   2 , Daniel Prieto-Alhambra  2   3 , Jonathan L Rees  1   2
Affiliations
Comparative Study

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

Epaminondas Markos Valsamis et al. BMJ. .

Abstract

Objectives: To 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.

Design: Population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England.

Setting: Public hospitals and publicly funded procedures at private hospitals in England, 2012-20.

Participants: Adults 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 measures: The 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.

Results: The 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.

Conclusions: This 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.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the National Institute for Health and Care Research (NIHR) and the NIHR Oxford Biomedical Research Centre (BRC) for the submitted work. EMV is a NIHR doctoral fellowship award holder. RPV is coapplicant on research grants to the NIHR to the University of Oxford. MRW is principal investigator or coapplicant on research grants to NIHR to the University of Bristol. JLR holds an NIHR senior investigator award and is immediate past president of the British Elbow and Shoulder Society. GSC is an NIHR senior investigator. MRW, AS, and JLR hold a contract with the National Joint Registry (FTS 010307-2022: Statistical Analysis, Support and Associated Services). GC is patient representative for the National Joint Registry. DPA receives funding from the NIHR in the form of a senior research fellowship and from the Oxford NIHR Biomedical Research Centre. DPA’s research group has received research grants from the European Medicines Agency, the Innovative Medicines Initiative, Amgen, Chiesi, and UCB Biopharma; and consultancy or speaker fees from Astellas, Amgen, AstraZeneca, and UCB Biopharma. All other authors declare no conflicts of interest.

Figures

Fig 1
Fig 1
Anatomical and reverse total shoulder replacements. Anatomical total shoulder replacement—prosthetic ball and socket replacement that matches normal ball and socket anatomy of shoulder joint. Reverse total shoulder replacement—prosthetic ball and socket replacement that reverses normal ball and socket anatomy of shoulder joint
Fig 2
Fig 2
Cohort state transition (Markov) model for cost analysis. p_UnR=time dependent (nth cycle) transition probability from unrevised state to revised state; p_UnD=time dependent (nth cycle) transition probability from unrevised state to dead state (unrevised state consisted of tunnel states, accounting for time dependency; revised and dead states are absorbing states with no transitions out of them); RTSR=reverse total shoulder replacement; TSR=anatomical total shoulder replacement
Fig 3
Fig 3
Data flowchart for linked National Joint Registry (NJR), Hospital Episode Statistics (HES), and civil registration mortality dataset
Fig 4
Fig 4
Treatment effects for primary outcome of revision using flexible parametric survival models. Upper panel shows survival probability for the two procedure types overlying Kaplan-Meier curves. Middle panel shows relative risk: time varying hazard ratio of RTSR with reference to TSR. Bottom panel shows absolute risk difference in RMST (RTSR − TSR). RMST=restricted mean survival time; RTSR=reverse total shoulder replacement; TSR=anatomical total shoulder replacement
Fig 5
Fig 5
Treatment effects for secondary outcomes using logistic regression models. RTSR=reverse total shoulder replacement; TSR=anatomical total shoulder replacement. “Events” represents the positive count of the outcome measure while “population” represents the at-risk cohort. Absolute risk difference=RTSR − TSR
Fig 6
Fig 6
Cost analysis results. Probabilistic sensitivity analysis results after 10 000 Monte Carlo simulations shown with 95% confidence intervals, together with deterministic mean results. RTSR=reverse total shoulder replacement; TSR=anatomical total shoulder replacement
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Comment in

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