New study sheds light on the debate surrounding two types of shoulder replacement surgery for osteoarthritis

Anatomical and reverse total shoulder replacements

Anatomical total shoulder replacement (TSR): a prosthetic ball and socket replacement that matches the normal ball and socket anatomy of the shoulder joint. Reverse total shoulder replacement (RTSR): a prosthetic ball and socket replacement that reverses the normal ball and socket anatomy of the shoulder joint University of Oxford

Press release issued: 1 May 2024

A new study has provided valuable insights into the ongoing debate surrounding two types of shoulder replacement surgery: reverse total shoulder replacement and anatomical total shoulder replacement as a treatment for patients with osteoarthritis.

The research, led by the University of Oxford and involving researchers from the University of Bristol, has found that reverse total shoulder replacements (RTSR) provide similar long-term outcomes to traditional anatomical total shoulder replacements (TSR) for patients aged 60 years or older with osteoarthritis (OA) and intact rotator cuff tendons.

The study published in the BMJ today [1 May] was funded by the National Institute for Health and Care Research (NIHR).

Shoulder OA is a common and debilitating condition, and shoulder replacement surgery is an effective treatment option for end-stage disease. TSR has long been considered the gold standard for treating patients with OA and intact rotator cuff tendons. However, the RTSR has surged in popularity since 2008 in the UK. Originally designed for a completely different surgical indication, it is now often used instead of TSR in this patient group.

This shift in practice is growing despite a lack of supporting evidence, and in 2020, the National Institute for Health and Care Excellence (NICE) identified this as a key research priority. Researchers from NDORMS, University of Oxford, and involving experts from the University of Bristol set out to provide high-quality evidence to help address this uncertainty.

Epaminondas Markos Valsamis, NIHR Doctoral Research Fellow at the University of Oxford and lead author, explained: “In recent years, the use of RTSR has increased, even for patients with intact rotator cuffs - a group traditionally treated with TSR. But treatment choices are being made without any good evidence, leading to concerns from healthcare agencies and patients about which procedure is the safest and most effective option.”

Dr Adrian Sayers, Senior Research Fellow in the Bristol Medical School: Translational Health Sciences (THS) and co-author, added: “This work shows the tremendous potential of routinely collected data in answering questions that are important to patients in a timely manner. It is reassuring for patients and surgeons to know that either reverse or traditional anatomic shoulder replacement for osteoarthritis is a safe and effective procedure. This question was asked and answered in a fraction of the time and cost of conventional randomised clinical studies.”

The research team conducted a population-based cohort study using linked data from the National Joint Registry and NHS Hospital Episode Statistics for England. Over 12,000 patients aged 60 years or older who underwent RTSR or TSR for OA with intact rotator cuff tendons between 2012 and 2020 were included in the study.

The researchers compared the outcomes of patients for each of the two types of procedures, focusing on factors such as revision surgery, serious adverse events, reoperations, hospital stay duration, and lifetime costs to the healthcare system.

The findings revealed that while TSR had a higher risk of revision surgery in the first three years after surgery, there was no important difference in the longer term, and both procedures were equally safe for patients.

"By the end of the study period we found no 'clinically important' difference in any outcome", said Epaminondas. "This provides reassurance to patients and surgeons that RTSR is an acceptable alternative for this patient group, and we found no evidence to change the growing surgical trend of offering RSTR to them."

While further research is needed to explore functional outcomes and to inform a full cost-effectiveness comparing RTSR and TSR, this study provides valuable insights that can help guide clinical practice by supporting patients and surgeons to make more informed decisions about the best treatment options in order to optimise patient outcomes.

The study was supported by the NIHR Oxford Biomedical Research Centre (BRC), NIHR Bristol Biomedical Research Centre (NIHR Bristol BRC) and the National Joint Registry.

Paper

'Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England' by Epaminondas Markos Valsamis et al. in BMJ

Further information

About the National Institute for Health and Care Research (NIHR)
The mission of the National Institute for Health and Care Research (NIHR) is to improve the health and wealth of the nation through research. We do this by:

Funding high quality, timely research that benefits the NHS, public health and social care;
Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
Funding applied global health research and training to meet the needs of the poorest people in low and middle income countries.

NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK Aid from the UK government.

About National Institute for Health and Care Research Bristol Biomedical Research Centre (NIHR Bristol BRC)
National Institute for Health and Care Research Bristol Biomedical Research Centre’s (NIHR Bristol BRC) innovative biomedical research takes science from the laboratory bench or computer and develops it into new drugs, treatments or health advice. Its world-leading scientists work on many aspects of health, from the role played by individual genes and proteins to analysing large collections of data on hundreds of thousands of people. Bristol BRC is unique among the NIHR's 20 BRCs across England, thanks to its expertise in ground-breaking population health research.

About the National Joint Registry (NJR)
The NJR, which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey, collects information on hip, knee, ankle, elbow and shoulder joint replacement surgery, across both the NHS and independent sector. Data collection began in April 2003 and data submission for NHS organisations was made mandatory from April 2011.

Now with around 3.7 million procedure records, the NJR is the largest orthopaedic registry in the world with an international reputation. Recognised as a ‘global exemplar’ of an implantable medical devices registry, the NJR monitors the performance and effectiveness of joint replacement implants in different types of joint replacement surgery, in order to provide an early warning of issues relating to patient safety and improve clinical standards; thus benefiting patients, clinicians and the orthopaedic sector as a whole.

For more information about the NJR see: https://www.njrcentre.org.uk