International trends in shoulder replacement: a meta-analysis from 11 public joint registers

Abstract

Background and purpose: International variation exists in the types of shoulder replacement used for treatment of specific diseases. Implant choice continues to evolve without high-quality evidence. Our aim was to evaluate trends in incidence rates of shoulder replacement and assess any recent changes in practice between countries by using registry data.

Methods: Patient characteristics, indication and year of surgery, type of replacement, and collection methods of patient-reported outcomes (PROMs) was extracted from 11 public joint registries. Meta-analyses examined use of reverse total shoulder replacement (RTSR) for osteoarthritis, cuff tear arthropathy, and acute fracture; use of anatomical total shoulder replacement (TSR) for osteoarthritis; and use of humeral hemiarthroplasty for fracture.

Results: The annual growth rate of shoulder replacements performed is 6-15% (2011-2019). The use of RTSR has almost doubled (93%). RTSR is now universally performed for cuff tear arthropathy (97.3%, 95% confidence interval [CI] 96.0-98.1). Its use for avascular necrosis, trauma, and inflammatory arthropathy is increasing. The use of RTSR was similar (43.1%, CI 30.0-57.2) versus TSR (44.7%, CI 31.1-59.1) for osteoarthritis. The types of PROMs used, collection time points, and response rates lack standardization. COVID-19 had a varying inter-registry impact on incidence rates.

Conclusion: The incidence of shoulder replacements has grown. Use of RTSR has increased for all disease indications despite limited high-quality evidence driving this change in indications outside of cuff arthropathy. Consequently, less variation is observed in international practice. Existing differences now relate to use of newer implant types and methodology of PROMs collection, which prevents international comparison and outcome analysis.

Figure 1

Annual incidence of shoulder replacement.

Figure 2

Distribution of indications for shoulder replacement.

Figure 3

Distribution of types of shoulder replacement procedures performed across registries for 6 specific indications.

Figure 4

5 different variation meta-analyses displayed as a forest plot for different procedure types for specific indicators to assess variation between registries.

Figure 5

Proportion of types of procedure performed over time.

Figure 6

Proportion of resurfacing humeral hemiarthroplasty performed against stemless hemiarthroplasty performed over 4 time intervals.

Figure 7

Proportion of stemmed versus stemless total anatomical shoulder replacement performed over 4 time intervals.