Anatomic vs. reverse total shoulder arthroplasty: usage trends and perioperative outcomes

Total shoulder arthroplasty (TSA) is a common orthopedic procedure for which there are anatomic TSA (aTSA) and reverse TSA (rTSA) options. The current study aimed to characterize the 2011-2020 utilization trends of aTSA and rTSA as well as assess and compare perioperative outcomes using a large, national, multi-insurance administrative data set. Data were utilized from the 2011 through 2020 M151 PearlDiver database. Trends in usage of aTSA relative to rTSA were characterized. For the more recent years (2015 through 2020), after 1:1 matching of patients based on age, sex, and Elixhauser Comorbidity Index, perioperative outcomes and surgeon volume were compared for the two procedures with univariable and multivariable analyses. From 2011 through 2020, a total of 148,231 TSAs were identified (aTSA 57,680 [38.9%]; rTSA 90,551 [61.1%]). Over this period, the yearly overall incidence of TSAs being performed increased from 5890 to 23,215 (an increase of 394.1%) and the percent of TSA being performed with rTSA increased from 31.4% to 74.9%. The increased percentage of rTSA was accounted for by increased numbers of rTSA, as opposed to decreased aTHA. When assessing patients from the more recent years (2015-2020), those undergoing rTSA were older, more female, and had a higher Elixhauser Comorbidity Index (P < .0001 for each). After matching for these criteria, 33,582 were available from each of the subcohorts for comparing perioperative outcomes. Of these matched patients, those undergoing rTSA (compared to aTSA) were of independently greater odds for: transfusion (odds ratio [OR] 1.92), wound dehiscence (OR 1.54), any adverse event (OR 1.29), sepsis (OR 1.46), acute kidney infection (OR 1.35), pneumonia (OR 1.30), urinary tract infection (OR 1.28), and severe adverse events (OR 1.16). For surgeon volume, there was a long right-tail where the average ± standard deviation was more than twice the median for both rTSA (average: 40.7 ± 78.9; median: 16 [39]) and aTSA (average: 39.2 ± 56.3; median: 18 [39]). From 2011 to 2020, the number of TSAs performed yearly increased by 394.1%, of which rTSA increased from 31.4% to 74.9%. This shows that rTSA has been a disruptive technology in TSA because it has expanded the TSA patient population. There were increased perioperative adverse events associated with rTSA vs. aTSA, which is not explained by patient demographics or comorbidities. Given the rapid adoption of rTSA and the low average annual volume of this procedure performed per surgeon (<7), the effect of surgeon volume on perioperative outcome following rTSA merits further investigation.