Abstract
Introduction
The annual utilization of reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (ATSA) has grown exponentially, in part due to the expanded indications of RTSA. This evolution in shoulder arthroplasty prompts the need to evaluate outcomes between ATSA and RTSA. However, many other studies comparing outcomes between ATSA and RTSA lacked a large nationally-represented sample, a matched cohort analysis, or both. In this study, we compare outcomes between patients undergoing ATSA or RTSA in a large matched-cohort analysis.
Methods
Patients undergoing RTSA or ATSA from the National Inpatient Sample database between 2016 and 2019 were identified. Groups were propensity-matched based on demographics and comorbidities. We compared medical and surgical complications, length of stay, and total hospital charges. T-tests and chi-square tests were performed for continuous and categorical variables, respectively. Odds ratios were calculated as a ratio between RTSA and ATSA groups.
Results
Following matching, there were 38,782 patients in the ATSA group and 35,461 patients in the RTSA group. The RTSA group had higher odds of acute renal failure (OR 1.35), blood loss anemia (OR 1.39), and pneumonia (OR 1.19). There were no differences for myocardial infarction, pulmonary embolism, deep venous thrombosis, mortality, periprosthetic fracture, or dislocation. The RTSA group had higher odds of periprosthetic mechanical complication (OR 1.92), but lower odds of periprosthetic joint infection (OR 0.65). The mean length of stay and total hospital charges were both higher in the RTSA group (p < 0.001).
Discussion
We found patients undergoing RTSA are at higher odds of inpatient medical complications, including acute renal failure and acute blood loss anemia. RTSA is associated with higher odds of short-term periprosthetic mechanical complications.
Keywords: Reverse, Anatomic, Shoulder, Matched, Complications, Cost
1. Introduction
The annual utilization of shoulder arthroplasty has grown exponentially over the past decade and growth rate projections outpace total hip and knee arthroplasties. Despite anatomic total shoulder arthroplasty (ATSA) historically being the gold standard for primary osteoarthritis of the shoulder, the rapid growth in shoulder arthroplasty in the United States is largely attributed to the increasing popularity of reverse total shoulder arthroplasty (RTSA). In 2017, there were approximately 62,000 RTSA procedures, compared to 42,000 ATSA procedures. From 2017 to 2025, the number of RTSAs annually performed is projected to increase by 353 % while ATSA by only 51 %.1,2
RTSA was mainly indicated for rotator cuff tear arthropathy and as salvage surgery for failed ATSA's and hemiarthroplasties.3 However, its expanded indications have led many surgeons to apply it for primary osteoarthritis as well as non-reconstructable displaced proximal humerus fractures for which hemiarthroplasty was previously the gold standard.1, 2, 3, 4 While RTSA has become more popular, even in patients with osteoarthritis and an intact rotator cuff, many studies have reported high complication rates following RTSA.5, 6, 7, 8 Additionally, RTSA has been shown to confer higher overall costs than ATSA.7,9 This calls into question whether the RTSA should be performed in preference of ATSA.
Many studies have compared outcomes between ATSA and RTSA, but they have their limitations. Kirsch et al.10 compared functional and radiographic outcomes between the two procedures in a matched analysis and found similar short-term patient-reported outcomes. However, they had a relatively smaller sample size with 67 patients in each group. Meanwhile, Ponce et al.9 examined a large sample of patients who underwent ATSA and RTSA from a national database and found RTSA had a higher risk of inpatient death, medical complications, hospital stay, and hospital cost. However, the aforementioned study did not have a matched-cohort analysis. Many other studies comparing functional outcomes and complications between patients undergoing ATSA and RTSA lacked a large nationally-represented sample, a matched cohort analysis, or both.11, 12, 13
In this study, we compare medical and surgical complications, length of stay, and total charges among patients from a nationally represented sample undergoing ATSA or RTSA in a matched-cohort analysis. This is the largest known study comparing ATSA and RTSA with a matched analysis.
2. Methods
This study employed the National Inpatient Sample (NIS) Database to collect patients undergoing ATSA and RTSA in the United States. Comprising information from inpatient billing and discharge records, this database includes resource utilization and clinical information related to inpatient hospital stays from academic and community health care systems. The database is the largest inpatient care database in the country, covering 47 states, and is representative of the national population. Since the NIS database is readily available to the public and does not contain any identifiable patient data, this study did not require approval from an Institutional Review Board.
Patients undergoing RTSA or ATSA between January 2016 and December 2019 were included. Those RTSA were identified with the International Classification of Diseases Tenth Revision) ICD-10 codes 0RRJ00Z and 0RRK00Z, while ATSA patients were identified with the ICD-10 codes, 0RRJ0J6, 0RRK0J6, 0RRJ0J7, 0RRK0J7, 0RRJ0JZ, and 0RRK0JZ. Medical and surgical complications were assessed and all diagnoses were identified using ICD-10 codes (Table 1). Demographic data, inpatient length of stay, and total charges were provided by the database directly.
Table 1.
ICD Codes used.
| Surgical Procedure Codes | Obese Codes | Comorbidities codes | Surgical Complications codes | Medical Complications codes |
|---|---|---|---|---|
| RTSA | E660 | Diabetes without complications | Periprosthetic fracture | Acute renal failure |
| 0RRK00Z, | E6601 | E119 | T84010A, T84011A, T84012A, T84013A, T84018A, T84019A, M9665, M96661, M96662, M96669, M96671, M96672, M96679, M9669, M9701XA, M9702XA, M9711XA, M9712XA | N170, N171, N172, N178, N179 |
| 0RRJ00Z | E6609 | Diabetes with complications | Myocardial infarction | |
| ATSA | E661 | E1169 | Periprosthetic dislocation | I2101, I2102, I2111, I2113, I12114, I12119, I2121, I12129, I21A1 |
| 0RRJ0J6, 0RRK0J6, 0RRJ0J7, 0RRK0J7, 0RRJ0JZ, 0RRK0JZ | E662 | Tobacco related disorder | T84020A, T84021A, T84022A, T84023A, T84028A, T84029A | Blood loss anemia |
| E668 | Z87891 | Periprosthetic mechanical complications | D62 | |
| E669 | T84090A, T84091A, T84092A, T84093A, T84098A, T84099A | Pneumonia | ||
| Z6830 | Periprosthetic joint infection | J189, J159, J22 | ||
| Z6831 | T8450XA, T8451XA, T8452XA, T8453XA, T8454XA, T8459XA | Blood transfusion | ||
| Z6832 | 30233N1 | |||
| Z6833 | Pulmonary embolism | |||
| Z6834 | I2602, I2609, I2692, I2699 | |||
| Z6835 | Deep venous thrombosis | |||
| Z6836 | I82401, I82402, I82403, I82409, I82411, I82412, I82413, I82419, I82421, I82422, I82423, I82429, I82431, I82432, I82433, I82439, I82441, I82442, I82443, I82449, I82491, I82492, I82493, I82499, I824Y1, I824Y2, I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, I824Z4 | |||
| Z6837 | ||||
| Z6838 | ||||
| Z6839 |
Means and standard deviations (SD) were calculated. We generated propensity-matched groups for patients who underwent ATSA and those who underwent RTSA based on sex, age, tobacco use, sex, obesity, tobacco use, and history of diabetes. An additional sub-analysis comparing ATSA to RTSA for patients over 60 years old undergoing surgery for primary osteoarthritis was also performed. For continuous variables, a T-test was performed and for categorical variables, a Chi-squared test was applied. For incidences less than five, a Fischer-Exact test was done. Odds ratios (OR) and 95 % confidence intervals (95 % CI) were calculated for postoperative complications, length of stay, and total hospital charges. Statistical significance was set as p-value <0.05.
3. Results
There were 98,706 patients who underwent ATSA or RTSA from January 2016 to December 2019. Of these, 38,782 (39.3 %) patients underwent ATSA, and 59,925 (60.7 %) patients underwent RTSA. Those who underwent RTSA were significantly older than those undergoing ATSA (71.4 ± 8.6 years versus 66.5 ± 10.1 years; p < 0.001). Patients who underwent RTSA were also more likely female versus those who underwent ATSA (60.5 % versus 50.4 %, p > 0.001) (Table 2).
Table 2.
Demographics of unmatched and matched cohorts.
| ATSA | RTSA | p-value | |
|---|---|---|---|
| Unmatched Total | 38782 | 59925 | na |
| Mean age (SD) | 66.5 years (10.1 years) | 71.4 years (8.6 years) | <0.001 |
| Female (%) | 19555 (50.4 %) | 36292 (60.5 %) | <0.001 |
| Diabetes (%) | 4750 (12.2 %) | 8657 (14.4 %) | <0.001 |
| Tobacco (%) | 6513 (16.8 %) | 9644 (16.1 %) | 0.004 |
| Obesity (%) | 8460 (21.8 %) | 11964 (20.0 %) | <0.001 |
| Matched Total | 38782 | 35461 | na |
| Female (%) | 19555 (50.4 %) | 18878 (53.2 %) | <0.001 |
| Diabetes (%) | 4750 (12.3 %) | 4567 (12.9 %) | 0.01 |
| Tobacco (%) | 6513 (16.8 %) | 5978 (16.9 %) | 0.82 |
| Obesity (%) | 9460 (24.4 %) | 7643 (21.6 %) | 0.39 |
| Age Categorical | <0.001 | ||
| <60 years (%) | 8524 (22.0 %) | 5265 (14.9 %) | |
| 60–69 years (%) | 14615 (37.7 %) | 14558 (41.0 %) | |
| 70–79 years (%) | 12468 (32.1 %) | 12465 (35.2 %) | |
| 80–89 years (%) | 3005 (7.8 %) | 3004 (8.5 %) | |
| 90+ years (%) | 169 (0.4 %) | 169 (0.5 %) |
After matching, there were 38,782 in the ATSA group and 35,461 in the RTSA group. For medical complications, the RTSA group had higher odds of acute renal failure (OR 1.35; 95 % CI (1.22–1.54); p < 0.001), blood loss anemia (OR 1.39; 95 % CI (1.33–1.47); p < 0.001), blood transfusion requirement (OR 1.69; 95 % CI (1.49–1.89); p < 0.001), and pneumonia (OR 1.19; 95 % CI (1.06–1.35); p < 0.005) compared to the ATSA group. There were no differences between the two groups for myocardial infarction, pulmonary embolism, deep vein thrombosis, and mortality. Concerning surgical complications, there were no differences in periprosthetic fracture or periprosthetic dislocation between the two groups. However, the RTSA group had higher odds of mechanical complication (OR 1.92; 95 % CI (1.67–2.22); p < 0.001), but lower odds of periprosthetic joint infection (OR 0.65; 95 % CI (0.55–0.77); p < 0.001) (Table 3).
Table 3.
Matched cohort analysis comparing complications between patients undergoing ATSA and RTSA.
| ATSA (n = 38782) | RTSA (n = 35461) | OR | 95 % CI Lower | 95 % CI Upper | p-value | |
|---|---|---|---|---|---|---|
| Medical Complications | ||||||
| Acute renal failure | 571 (1.5 %) | 705 (2.0 %) | 1.35 | 1.22 | 1.54 | <0.001 |
| Myocardial infarction | a (0.02 %) | 12 (0.03 %) | 1.89 | 0.74 | 4.76 | 0.18 |
| Blood loss anemia | 2854 (7.4 %) | 3547 (10.0 %) | 1.39 | 1.33 | 1.47 | <0.001 |
| Blood transfusion | 438 (1.1 %) | 670 (1.9 %) | 1.69 | 1.49 | 1.89 | <0.001 |
| Pneumonia | 106 (0.3 %) | 139 (0.4 %) | 1.19 | 1.06 | 1.35 | 0.005 |
| Pulmonary embolism | 29 (0.1 %) | 41 (0.1 %) | 1.54 | 0.96 | 2.5 | 0.07 |
| Deep venous thrombosis | 16 (0.04 %) | 24 (0.1 %) | 1.64 | 0.87 | 3.13 | 0.12 |
| Surgical Complications | ||||||
| Periprosthetic fracture | 109 (0.3 %) | 81 (0.2 %) | 0.81 | 0.61 | 1.09 | 0.16 |
| Periprosthetic dislocation | 808 (2.1 %) | 684 (1.9 %) | 0.93 | 0.83 | 1.02 | 0.13 |
| Periprosthetic mechanical complication | 287 (0.7 %) | 504 (1.4 %) | 1.92 | 1.67 | 2.22 | <0.001 |
| Periprosthetic infection | 373 (1.0 %) | 223 (0.6 %) | 0.65 | 0.55 | 0.77 | <0.001 |
For privacy reasons, values between 1 and 10 are not allowed to be published according to the Health Care Utility Project (HCUP) data use agreement.
The mean length of stay for patients undergoing RTSA was longer than those undergoing ATSA (1.9 ± 2.0 days versus 1.7 ± 1.9 days; p < 0.001). The total hospital charges for RTSA were on average more than that for ATSA ($67,845.85 ± $46,020.04 versus $79,687.87 ± $48,782, p < 0.001). Following matching, the RTSA patient group also had a longer length of stay and higher mean total hospital charges than the ATSA group (Table 4).
Table 4.
Length of stay and total charges in unmatched and matched cohorts.
| Unmatched ATSA | Unmatched RTSA | p-value | Matched ATSA | Matched RTSA | p-value | |
|---|---|---|---|---|---|---|
| Length of stay; mean (SD) | 1.7 (1.9) | 1.9 (2.0) | <0.001 | 1.7 (2.0) | 1.9 (2.1) | <0.001 |
| Total charges; mean (SD) | $67,845.85 ($46,020.04) | $79,687.87 ($48,782.56) | <0.001 | $67,845.85 ($46,020.04) | $77,299.27 ($46,712.30) | <0.001 |
Sub-analysis comparing RTSA to ATSA for patients with primary osteoarthritis over 60 years old revealed the RTSA group also had higher odds of acute renal failure (OR 1.54; 95 % CI (1.32–1.80); p < 0.001), blood loss anemia (OR 1.34; 95 % CI (1.25–1.43); p < 0.001) and blood transfusion requirement (OR 2.32; 95 % CI (1.84–2.92); p < 0.001). However, while there was no difference in the rate of pneumonia between the two groups, the RTSA group had a higher rate of myocardial infarction (OR 3.56; 95 % CI (1.00–12.61); p = 0.04). Among surgical complications, while the RTSA group also had higher odds of mechanical complications (OR 4.45; 95 % CI (1.01–20.30); p = 0.04), there was no difference in periprosthetic infections (Table 5).
Table 5.
Complications between patients undergoing ATSA and RTSA for primary osteoarthritis.
| ATSA (n = 25,694) | RTSA (n = 28,901) | OR | 95 % CI Lower | 95 % CI Upper | p-value | |
|---|---|---|---|---|---|---|
| Medical Complications | ||||||
| Acute renal failure | 250 (1.0 %) | 431 (1.5 %) | 1.54 | 1.32 | 1.80 | <0.001 |
| Myocardial infarction | a (0.01 %) | 12 (0.04 %) | 3.56 | 1.00 | 12.61 | 0.04 |
| Blood loss anemia | 1612 (6.3 %) | 2371 (8.2 %) | 1.34 | 1.25 | 1.43 | <0.001 |
| Blood transfusion | 101 (0.4 %) | 262 (0.9 %) | 2.32 | 1.84 | 2.92 | <0.001 |
| Pneumonia | 49 (0.2 %) | 75 (0.3 %) | 1.36 | 0.95 | 1.95 | 0.09 |
| Pulmonary embolism | 16 (0.06 %) | 19 (0.07 %) | 1.06 | 0.54 | 2.05 | 0.87 |
| Deep venous thrombosis | a (0.03 %) | 11 (0.04 %) | 1.22 | 0.49 | 3.04 | 0.66 |
| Surgical Complications | ||||||
| Periprosthetic fracture | 18 (0.07 %) | 20 (0.07 %) | 0.99 | 0.52 | 1.87 | 0.97 |
| Periprosthetic dislocation | a (0.03 %) | 16 (0.06 %) | 2.03 | 0.84 | 4.94 | 0.11 |
| Periprosthetic mechanical complication | a (0.01 %) | 10 (0.03 %) | 4.45 | 1.01 | 20.30 | 0.04 |
| Periprosthetic infection | a (0.01 %) | a (0.01 %) | 1.78 | 0.33 | 9.71 | 0.51 |
For privacy reasons, values between 1 and 10 are not allowed to be published according to the Health Care Utility Project (HCUP) data use agreement.
4. Discussion
Shoulder arthroplasty utilization continues to rise at a remarkable rate, especially due to the popularity of RTSA over the past decade.14,15 However, the cost burden and complications associated with RTSA raise practical concerns, especially as surgeons continue employing the procedure for expanded indications.3,16, 17, 18 Previous studies comparing RTSA and ATSA have either lacked a large nationally represented sample size or a matched cohort analysis, or both.11, 12, 13 The NIS database is the largest available dataset of inpatient information in the United States and provides the necessary cohort size to adequately capture rare complications. In this study, we employed the NIS database to compare complications, cost, and length of stay between patients undergoing ATSA or RTSA in a matched-cohort analysis.
We found RTSA patients were at higher risk for medical complications including acute renal failure, pneumonia, anemia, and blood transfusion requirement. Our results are supported by previous literature. Both Ponce et al.9 and Ross et al.6 compared the two procedures and also found RTSA was more likely associated with renal failure, pneumonia, blood loss anemia, and transfusion compared to ATSA, following multivariate analysis. Interestingly, when comparing the two surgeries performed for primary osteoarthritis, there was no difference in the rate of pneumonia, suggesting the difference may have been due to more medically complex patients with proximal humerus fractures undergoing RTSA. Our findings are also similar to both studies which did not find any difference in the incidence of myocardial infarction between ATSA and RTSA. However, when performed for primary osteoarthritis, the RTSA group had higher odds of myocardial infarction, due to fewer patients with ATSA sustaining a myocardial infarction in the analysis. This difference may be due to patient pre-operative optimization and patient selection of ATSA for primary osteoarthritis, as opposed to ATSA for revision surgeries when patients may be more medically complex or when pre-operative optimization is limited. Other previous studies have similarly found RTSA associated with more medical complications than ATSA as well.7,19
We found patients undergoing RTSA had higher odds of periprosthetic mechanical complications. Similarly, Liu et al.20 also found RTSA had a higher incidence of implant-related mechanical complications than ATSA, even in the setting of rotator cuff deficiency for ATSA. Early studies analyzing RTSA have yielded a high complication rate including instability.4,21,22 RTSA is a relatively newer and technically demanding procedure where instability and mechanical complications are the most common postoperative complications. These usually present within the first six months following surgery.23,24 Notably, the learning curve for RTSA is steep, and complications for low-volume surgeons are not insignificant, especially as it pertains to proper implant placement.25,26 Scapular notching is also a common problem specific to RTSA that can occur if the glenosphere is not properly positioned. This may contribute to polyethylene wear, joint inflammation, osteolysis, and subsequent implant loosening.27,28 Therefore, Choi et al.29 warned that surgeons within the learning curve period for RTSA should exercise caution when selecting patients for the procedure.
We found that ATSA was more associated with periprosthetic joint infections. A previous study comparing infection rates among shoulder arthroplasties found that ATSA had the greatest proportion of infections (2.0 %), followed by hemiarthroplasty (1.0 %), and RTSA at 0.3 %.30 However, this is in contrast to many studies which have found RTSA has either a higher or similar rate of periprosthetic infection compared to ATSA.5,6,9,31 It is unclear why ATSA had a higher proportion of PJIs in our study and Schick's study, especially since RTSA is often performed for revision of previous arthroplasties. One explanation is that despite matching for general age distribution, the ATSA group still had more patients who were less than 60 years old than the RTSA group. This is supported by the sub-analysis comparing patients over 60 years old revealing no difference in the infection rate, whereas the matched analysis, which included patients younger than 60 years old, favored ATSA for infections. There is evidence that young patients undergoing shoulder arthroplasty, commonly ATSA, are at higher risk for PJI with commensal bacteria, such as C. acnes.32,33 RTSA, on the other hand, is not commonly indicated in the young population.
The RTSA group had a longer length of stay and higher overall charges compared to ATSA, which is consistent with previous studies.7,9 The longer length of stay may be related to the higher risk of post-operative medical complications among RTSA patients, which requires additional workup and treatment. While additional days in the hospital could contribute to overall hospital costs, a critical factor may be the differences in implant costs. The implant itself is a major contributor to overall inpatient costs, estimated to be around 60 %, while RTSA implants are usually more expensive than ATSA implants.34, 35, 36 However, implant costs can be negotiated with hospital contracts to reduce costs. Fang et al.37 compared costs excluding implants and found RTSA and ATSA had similar hospital costs. They found that RTSA had shorter operating room times, but the cost savings were offset by patients having a longer post-operative hospital stay.
The study's primary limitation is that the data is derived from a national patient registry, which is reliant on accurate coding and documentation from providers. Therefore, there may be some underreporting of medical and surgical complications. Additionally, the data in the NIS is based on inpatient ICD-10 codes so it is limited to only short-term outcomes within the inpatient setting. Nonetheless, the low surgical complication rates are consistent with previous studies with longer-term follow-ups.5,6 Due to the ICD-10 code-based database, clinical data such as patient-reported outcomes are not available. These are inherent limitations with any database study that uses insurance claims data. We are also unable to specify whether patients had a previous surgical shoulder procedure. There are several strengths of this study. The large patient cohort obtained from the national database affords the necessary estimate of the rare complications. Many previous studies only had less than 100 patients in each group which would be insufficient to capture and compare complications that occur less than 2 % of the time. This is the largest known patient cohort comparing ATSA and RTSA in a matched analysis. Finally, this study is generalizable as the NIS database provides a national representation of the U.S. patient population.
5. Conclusion
We found patients undergoing RTSA are at higher odds of inpatient medical complications, including acute renal failure and acute blood loss anemia. RTSA is associated with higher odds of short-term mechanical complications. Future studies should examine the costs and complications between the two procedures with long-term follow-up and with a large, representative patient population.
Source of funding
No funding was received to assist with the preparation of this manuscript.
Ethical committee approval
This study was exempt from IRB approval since the data was de-identified and publicly available.
Ethical statement
Regarding ethical committee approval, our study (Reverse Versus Anatomic Total Shoulder Arthroplasty: A Large Matched Cohort Analysis) was exempt from IRB approval since the data was de-identified and publicly available.
Funding statement
Our study, Reverse Versus Anatomic Total Shoulder Arthroplasty: A Large Matched Cohort Analysis, did not have any sources of funding.
Guardian/patient's consent
Our study, Reverse Versus Anatomic Total Shoulder Arthroplasty: A Large Matched Cohort Analysis, obtained information from a national database where the data is de-identified and publicly available, therefore there no consent process was required.
CRediT authorship contribution statement
Dang-Huy Do: Data processing, Validation, Writing – original draft, Writing – review & editing, Visualization, Project administration. Anubhav Thapaliya: Writing – original draft, Writing – review & editing, Visualization. Senthil Sambandam: Conceptualization, Methodology, Software, Formal analysis, Data curation, Writing – review & editing, Supervision, Project administration.
Declaration of competing interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Acknowledgements
There are no further acknowledgements.
Contributor Information
Dang-Huy Do, Email: Dang-Huy.Do@utsouthwestern.edu.
Anubhav Thapaliya, Email: Anubhav.Thapaliya@utsouthwestern.edu.
Senthil Sambandam, Email: sambandamortho@gmail.com.
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