Summary

Short-term revision and complication rates in this physician reported database were significantly higher than previously reported

Abstract

Reverse shoulder replacement (RTSA) has been an exciting new technology to manage complex arthroplasty problems in the shoulder. While the published result of experienced arthroplasty surgeons has been good, the experience of orthopedists early in their career performing this procedure has not been evaluated. Presented here are the results of the American Board of Orthopedic Surgeons (ABOS) Part II candidates with 2638 reverse shoulder replacements over a 12-year period.
Part II candidates submit a six-month case list to the ABOS. In the present study, the database was searched for the American Board of Orthopedic Surgery Part II from 1999 through 2017 to evaluate changes in the prevalence of RTSA performed over time and to identify available outcomes and associated complications of these procedures. The database first reported reverse cases in 2005. ABOS data base was searched for patient gender, age, diagnosis at surgery by ICD and CPT Codes, follow-up, and self-reported complications, and then stratified by year and presence or absence of fellowship training.
2638 cases were identified in the ABOS database, with RTSA as a percentage of all applicants total reported cases increasing to 0.17% in 2017. The applicant’s vignette, CPT, and ICD information allowed successful establishment of a definitive diagnosis in all but three cases (0.0011%). For all RTSA, 64% of cases were female. The mean age for the cohort was 72 years (range 14 to 96). For the entire cohort mean follow-up averaged 9.6 weeks (range 0-30 weeks). The ABOS database demonstrated a 20-fold increase in the number of reverse cases performed per year from 2005 to 2017 (Figure 1). The mean number of reverse cases/candidate of those candidates performing at least one reverse was 3.4 cases, representing only 2.61% of these candidates’ cases. The overall device related complication rate was 19.03%. The highest percentage of device related complications was fractures, at 3.53% overall versus 5.22% for fellowship trained applicants. Device related complications were not decreased by fellowship training.
Cases of reverse replacement steadily increased each year for ABOS candidates, consistent with reviews of other large databases demonstrating an increase in reverse arthroplasty with time. The 19.03% incidence of device related complication rates and 1% mortality rate remains disturbingly high, especially for less than 90-day follow-up and the self-reported nature of the complications. This rate is higher than for previous registry based reviews of 90-day reverse outcomes of all adverse events (5.7%). This cannot be explained solely based on case mix, as the majority of ABOS candidate cases were primary reverse shoulder arthroplasty (Figure 1). The failure of fellowship training to decrease complications may be due to the selection of more challenging cases by these applicants. Given the current survivorship data on this prosthesis and the high cost both procedure and subsequent revisions, closer adherence to the current established guidelines for this prosthesis may be warranted, and volume criteria for performing reverse replacement may be indicated, as has been suggested by authors using the ABOS database to assess candidates’ performance of hip arthroscopy.