Increasing utilization of reverse total shoulder arthroplasty in elderly patients over age 65

Abstract

BackgroundAt present, there is a paucity of literature comparing anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) in the elderly population. The aim of this study was to 1) observe the utilization and 2) compare the risk of 90-day surgical site infection (SSI) as well as 2-year and 5-year revision surgery (all-cause and periprosthetic joint infection [PJI]–related) between elderly patients who underwent ATSA and RTSA. MethodsElderly patients (age > 65) who underwent primary RTSA or ATSA between 2010 and 2015 with minimum 5-year follow-up were identified using a national claims database (PearlDiver Technologies). Identification of RTSA vs. ATSA was performed using International Classification of Diseases Ninth Edition and Tenth Revision procedure codes. Trends in utilization were stratified by age (65-69, 70-74, and >75) and reported in terms of compounded annual growth rates (CAGRs). Bivariate analysis was conducted to detect differences in patient demographics, baseline comorbidities, and primary outcome measures; 90-day SSI, 2-year and 5-year revision rates. Significant outcome measures found on bivariate analysis were evaluated on multivariable regression analyses, controlling for baseline patient demographics and comorbidities. ResultsRTSA (58.66% utilization) was the most performed shoulder arthroplasty procedure in those 65 and older. From 2010 to 2019, there has been an increase in utilization of RTSA in this population (CAGR: +6.76%; P < .001). This trend held true when stratifying by age group and was most pronounced increase in those aged between 70 and 74 (CAGR: +9.22%) compared with those aged between 65 and 69 and >75 years (CAGR: +6.50% and +8.16%, respectively). Alternatively, ATSA had significantly decreased utilization for all age ranges, with a greater decrease in those >75 (CAGR: −12.24%) compared with those between 65 and 69 and 70 and 74 years (CAGR: −5.50% and −8.10%, respectively). In terms of complication rates, there was no difference in the 2-year and 5-year all-cause revision rates between elderly patients who underwent RTSA vs. ATSA. After controlling for patient demographics and comorbidities, however, elderly RTSA patients had greater odds of having 90-day SSI (odds ratio [OR] = 3.4), 2-year PJI-related revision (OR = 2.0), and 5-year PJI-related revision (OR = 1.6) relative to ATSA patients (P < .05 for all). ConclusionOur study suggests that although there has been increased utilization of RTSA, ATSA may be a legitimate option for elderly patients with glenohumeral osteoarthritis, as there were no significant differences in overall 5-year implant survival and complication rates. Longer term follow-up is mandated to determine whether degenerative rotator cuff pathology might affect ATSA survivability among elderly patients.