Commentary In their study, Kirsch and colleagues evaluated the outcomes of anatomic (TSA) and reverse (RSA) total shoulder arthroplasty for the treatment of glenohumeral osteoarthritis in patients with an intact rotator cuff. In this retrospective, matched-cohort study, short-term results demonstrated improved patient-reported outcomes and a low rate of complications in both groups, with slightly better range of motion in the TSA group. This article is of interest due to the increasing prevalence of and expanding indications of RSA. In this study, matching was performed using preoperative function and patient-specific factors to better compare the outcomes of both implant designs. However, selection bias is still a limitation of this study design. Patients were selected for TSA or RSA based on surgeon preference; this implies differences between the groups that factored into the surgeon’s decision, which may impact the results. Additionally, the procedures were performed by a single surgeon with extensive shoulder arthroplasty experience. This should give readers pause when interpreting the results and how these results impact each surgeon’s current practice. There is evidence that surgeon experience leads to superior results for RSA1,2, although it does appear that improvements in training and implant design are narrowing this gap3. The results of this study showed generally similar improvement postoperatively among patients with matched preoperative ASES scores. This finding may contrast reports that show an association between patient dissatisfaction with TSA when the preoperative ASES score is lower4 and dissatisfaction with RSA when the preoperative ASES score is higher5. The conflict may be due to patient sampling and inherent difficulty with cohort matching. As stated earlier, the retrospective nature of the study by Kirsch et al. does raise questions about how the decision was made to perform TSA or RSA in otherwise similar patients. When weighing the risk of revision of TSA due to rotator cuff failure and aseptic glenoid loosening against slightly greater improvements in range of motion, it is tempting to move our indications toward RSA in older and lower-demand patients. However, using survivorship free from revision as the primary factor in deciding to perform RSA may be short-sighted. The complications and failures of TSA and RSA are as different and unique as the implants themselves. When considering revision rates, care should be taken to acknowledge that revision may not be an option in what is otherwise considered to be a failed implant or poor patient outcome after RSA. In a recent large database study comparing the complication and revision rates of these implants at a mean of 30 months, Parada et. al. reported that revision rates were higher for TSA yet complications rates were similar3. This discordance is largely driven by issues such as acromial insufficiency fracture and persistent pain—complications that are 2 of the 3 most frequently encountered complications associated with RSA. These complications not only lead to compromised patient outcomes but also do not have reliable solutions. In contrast, TSA failure can be corrected with revision to RSA in most circumstances. Certainly, we aim to make each patient’s first procedure their last procedure; however, issues such as those mentioned above should not be ignored. Additional research is needed to compare TSA and RSA in similar patient populations (as was done in this study) focusing on intermediate to long-term outcomes. Kirsch and colleagues have contributed valuable information to the debate between TSA and RSA in patients with osteoarthritis and should be congratulated for doing so. Matched cohort studies help to shed light on the differences and similarities associated with these procedures, but longer-term follow-up is needed. Ultimately, a prospective randomized trial is needed for true comparison between these 2 procedures. The decision to perform TSA or RSA is complex and involves multiple patient and surgeon-related factors. Despite the evidence presented in this study, TSA is still our preferred treatment for most patients with osteoarthritis and a functional rotator cuff.
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