A few weeks ago, a patient asked whether he could get my opinion on something unrelated to his yellow fever vaccine visit: He asked what I thought about the human papillomavirus (HPV) vaccine. His daughter’s primary care physician (PCP) had recommended it, but he “heard that it wasn’t safe.” We had a brief discussion.

My pediatric training days have long since ended, but I was taught never to miss an opportunity to immunize. In this case, it was to help a parent decide to immunize. This type of encounter is not unusual because, as part of preparing persons for international travel, I review their routine immunizations. When documentation of a vaccine is absent, it is pointed out and often remedied after a brief discussion.

Unfortunately, with HPV, too often parents state “my primary care physician said” it was optional, it was not required, or it was never recommended. Some were told to wait until their child was older, and several have safety concerns as did the parent above. I sometimes hear, “it’s not necessary for my child”; this is usually a clue indicating that the issue is more likely about how HPV is transmitted than what HPV vaccine can prevent. Most have welcomed the opportunity to discuss the vaccine, hear about its benefits, and have their questions answered. All leave with HPV information and are directed to websites that provide accurate information. They are referred to their PCP – hopefully to be immunized.

Three vaccines – meningococcal conjugate vaccine (MCV), Tdap, and HPV vaccine – all are recommended for administration at 11-12 years of age. A booster of MCV is recommended at 16 years. However, let’s focus on HPV. In 2007, HPV administration was recommended by the Advisory Committee on Immunization Practices (ACIP) for girls; by 2011, the recommendation was extended to boys. It was a three-dose schedule expected to be completed by age 13 years. In December 2016, a two-dose schedule administered at least 6 months apart was recommended for teens who initiated immunization at less than 15 years. Three doses were still recommended for those initiating HPV after 15 years. This was the only time the number of doses to complete a vaccine series had been decreased based on postlicensure data. So how well are we protecting our patients from HPV-related cancers?
 

Vaccine coverage

The National Immunization Survey–Teen (NIS-Teen) monitors vaccine coverage annually amongst adolescents aged 13-17 years. Data are obtained from individuals from every state, as well as the District of Columbia, the U.S. Virgin Islands, and six major urban areas.

According to the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (2018 Aug 24;67[33]:909-17), HPV vaccination continues to lag behind Tdap and MCV in 2018. Among all adolescents, coverage with one or more doses of HPV was 66%, with up-to-date HPV status in 49%. In contrast, 82% received a dose of MCV, and 89% received a dose of Tdap.

Coverage for receiving one or more doses of HPV among females was 69%, and up-to-date HPV status was 53%; among males, coverage with one or more doses was 63%, and up-to-date HPV status was 44%.

Up-to-date HPV coverage status differed geographically, ranging from 29% in Mississippi to 78% in DC. Overall, eight states and the District of Columbia reported increases in up-to-date status (District of Columbia, Louisiana, Massachusetts, Nebraska, North Carolina, South Carolina, Texas, Vermont, and Virginia). Kudos to Virginia for having the largest increase (20 percentage points).

Coverage also differed between urban and rural areas: one or more doses at 70% vs. 59% and up-to-date status at 52% vs. 42%.

HPV coverage differed by poverty level as well. It was higher for persons living below the poverty level, with one or more doses in 73% and up-to-date status in 54%, compared with persons living at or above poverty level at 63% and 47%, respectively.
 

HPV-related cancers

The most recent CDC data regarding types of HPV-associated cancers during 2011-2015 suggest that HPV types 16 and 18 account for the majority of cervical (78%) and oropharyngeal (86%) cancers.

Currently, there are more cases of oropharyngeal cancer than cervical, and we have no screening tool for the former.
 

Safety

Safety has been well documented. Since licensure, no serious safety concerns have been identified, contrary to what has been reported on various social and news media outlets. Yet it remains a concern for many parents who have delayed initiation of vaccine. Efficacy also has been documented in the United States and abroad.

Suggestions for improving HPV immunization coverage

Here are eight suggestions to help you recommend the vaccine and convince hesitant parents of its necessity:

1. Focus on your delivery of the HPV immunization recommendation. Clinician recommendation is the No. 1 reason parents vaccinate. The tone you use and how you make the recommendation can affect how the parent perceives the importance of this vaccine. The following are components of a high-quality recommendation (Academic Pediatrics. 2018;18:S23-S27):

• Routinely recommend vaccine at 11-12 years.
• Recommend vaccine for all preteens, not just those you feel are at risk for infection.
• Recommend the vaccine be given the same day it is discussed.
• Use language that expresses the importance of the HPV vaccine.

2. Use the “announcement or presumptive approach.” You expect the parent to agree with your recommendation. You don’t want to convey that it is an option.

3. Remind parents that immunizing on time means only two doses of HPV.

4. Revisit the topic again during another visit if a parent declines. Data suggest secondary acceptance can be as high as 66%.

5. Consider using a motivational interviewing approach for parents who are very hesitant to vaccinate. Most people want to comply with recommended health interventions.

6. Educate your staff about the importance of HPV vaccine and how it prevents cancer.

7. Determine how well your practice immunizes adolescents. This would be a perfect quality improvement project.

8. Explore “Answering Parents’ Questions” and other resources at www.cdc.gov/hpv to find quick answers to HPV vaccine–related questions .

Why is HPV coverage, a vaccine to prevent cancer, still lagging behind Tdap and MCV? I am as puzzled as others. What I do know is this: Our children will mature and one day become sexually active. They can be exposed to and get infected with HPV, and we can’t predict which ones will not clear the virus and end up developing an HPV-related cancer in the future. At the end of the day, HPV vaccination is cancer prevention.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

A few weeks ago, a patient asked whether he could get my opinion on something unrelated to his yellow fever vaccine visit: He asked what I thought about the human papillomavirus (HPV) vaccine. His daughter’s primary care physician (PCP) had recommended it, but he “heard that it wasn’t safe.” We had a brief discussion.

My pediatric training days have long since ended, but I was taught never to miss an opportunity to immunize. In this case, it was to help a parent decide to immunize. This type of encounter is not unusual because, as part of preparing persons for international travel, I review their routine immunizations. When documentation of a vaccine is absent, it is pointed out and often remedied after a brief discussion.

Unfortunately, with HPV, too often parents state “my primary care physician said” it was optional, it was not required, or it was never recommended. Some were told to wait until their child was older, and several have safety concerns as did the parent above. I sometimes hear, “it’s not necessary for my child”; this is usually a clue indicating that the issue is more likely about how HPV is transmitted than what HPV vaccine can prevent. Most have welcomed the opportunity to discuss the vaccine, hear about its benefits, and have their questions answered. All leave with HPV information and are directed to websites that provide accurate information. They are referred to their PCP – hopefully to be immunized.

Three vaccines – meningococcal conjugate vaccine (MCV), Tdap, and HPV vaccine – all are recommended for administration at 11-12 years of age. A booster of MCV is recommended at 16 years. However, let’s focus on HPV. In 2007, HPV administration was recommended by the Advisory Committee on Immunization Practices (ACIP) for girls; by 2011, the recommendation was extended to boys. It was a three-dose schedule expected to be completed by age 13 years. In December 2016, a two-dose schedule administered at least 6 months apart was recommended for teens who initiated immunization at less than 15 years. Three doses were still recommended for those initiating HPV after 15 years. This was the only time the number of doses to complete a vaccine series had been decreased based on postlicensure data. So how well are we protecting our patients from HPV-related cancers?
 

Vaccine coverage

The National Immunization Survey–Teen (NIS-Teen) monitors vaccine coverage annually amongst adolescents aged 13-17 years. Data are obtained from individuals from every state, as well as the District of Columbia, the U.S. Virgin Islands, and six major urban areas.

According to the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (2018 Aug 24;67[33]:909-17), HPV vaccination continues to lag behind Tdap and MCV in 2018. Among all adolescents, coverage with one or more doses of HPV was 66%, with up-to-date HPV status in 49%. In contrast, 82% received a dose of MCV, and 89% received a dose of Tdap.

Coverage for receiving one or more doses of HPV among females was 69%, and up-to-date HPV status was 53%; among males, coverage with one or more doses was 63%, and up-to-date HPV status was 44%.

Up-to-date HPV coverage status differed geographically, ranging from 29% in Mississippi to 78% in DC. Overall, eight states and the District of Columbia reported increases in up-to-date status (District of Columbia, Louisiana, Massachusetts, Nebraska, North Carolina, South Carolina, Texas, Vermont, and Virginia). Kudos to Virginia for having the largest increase (20 percentage points).

Coverage also differed between urban and rural areas: one or more doses at 70% vs. 59% and up-to-date status at 52% vs. 42%.

HPV coverage differed by poverty level as well. It was higher for persons living below the poverty level, with one or more doses in 73% and up-to-date status in 54%, compared with persons living at or above poverty level at 63% and 47%, respectively.
 

HPV-related cancers

The most recent CDC data regarding types of HPV-associated cancers during 2011-2015 suggest that HPV types 16 and 18 account for the majority of cervical (78%) and oropharyngeal (86%) cancers.

Currently, there are more cases of oropharyngeal cancer than cervical, and we have no screening tool for the former.
 

Safety

Safety has been well documented. Since licensure, no serious safety concerns have been identified, contrary to what has been reported on various social and news media outlets. Yet it remains a concern for many parents who have delayed initiation of vaccine. Efficacy also has been documented in the United States and abroad.

Suggestions for improving HPV immunization coverage

Here are eight suggestions to help you recommend the vaccine and convince hesitant parents of its necessity:

1. Focus on your delivery of the HPV immunization recommendation. Clinician recommendation is the No. 1 reason parents vaccinate. The tone you use and how you make the recommendation can affect how the parent perceives the importance of this vaccine. The following are components of a high-quality recommendation (Academic Pediatrics. 2018;18:S23-S27):

• Routinely recommend vaccine at 11-12 years.
• Recommend vaccine for all preteens, not just those you feel are at risk for infection.
• Recommend the vaccine be given the same day it is discussed.
• Use language that expresses the importance of the HPV vaccine.

2. Use the “announcement or presumptive approach.” You expect the parent to agree with your recommendation. You don’t want to convey that it is an option.

3. Remind parents that immunizing on time means only two doses of HPV.

4. Revisit the topic again during another visit if a parent declines. Data suggest secondary acceptance can be as high as 66%.

5. Consider using a motivational interviewing approach for parents who are very hesitant to vaccinate. Most people want to comply with recommended health interventions.

6. Educate your staff about the importance of HPV vaccine and how it prevents cancer.

7. Determine how well your practice immunizes adolescents. This would be a perfect quality improvement project.

8. Explore “Answering Parents’ Questions” and other resources at www.cdc.gov/hpv to find quick answers to HPV vaccine–related questions .

Why is HPV coverage, a vaccine to prevent cancer, still lagging behind Tdap and MCV? I am as puzzled as others. What I do know is this: Our children will mature and one day become sexually active. They can be exposed to and get infected with HPV, and we can’t predict which ones will not clear the virus and end up developing an HPV-related cancer in the future. At the end of the day, HPV vaccination is cancer prevention.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

A few weeks ago, a patient asked whether he could get my opinion on something unrelated to his yellow fever vaccine visit: He asked what I thought about the human papillomavirus (HPV) vaccine. His daughter’s primary care physician (PCP) had recommended it, but he “heard that it wasn’t safe.” We had a brief discussion.

My pediatric training days have long since ended, but I was taught never to miss an opportunity to immunize. In this case, it was to help a parent decide to immunize. This type of encounter is not unusual because, as part of preparing persons for international travel, I review their routine immunizations. When documentation of a vaccine is absent, it is pointed out and often remedied after a brief discussion.

Unfortunately, with HPV, too often parents state “my primary care physician said” it was optional, it was not required, or it was never recommended. Some were told to wait until their child was older, and several have safety concerns as did the parent above. I sometimes hear, “it’s not necessary for my child”; this is usually a clue indicating that the issue is more likely about how HPV is transmitted than what HPV vaccine can prevent. Most have welcomed the opportunity to discuss the vaccine, hear about its benefits, and have their questions answered. All leave with HPV information and are directed to websites that provide accurate information. They are referred to their PCP – hopefully to be immunized.

Three vaccines – meningococcal conjugate vaccine (MCV), Tdap, and HPV vaccine – all are recommended for administration at 11-12 years of age. A booster of MCV is recommended at 16 years. However, let’s focus on HPV. In 2007, HPV administration was recommended by the Advisory Committee on Immunization Practices (ACIP) for girls; by 2011, the recommendation was extended to boys. It was a three-dose schedule expected to be completed by age 13 years. In December 2016, a two-dose schedule administered at least 6 months apart was recommended for teens who initiated immunization at less than 15 years. Three doses were still recommended for those initiating HPV after 15 years. This was the only time the number of doses to complete a vaccine series had been decreased based on postlicensure data. So how well are we protecting our patients from HPV-related cancers?
 

Vaccine coverage

The National Immunization Survey–Teen (NIS-Teen) monitors vaccine coverage annually amongst adolescents aged 13-17 years. Data are obtained from individuals from every state, as well as the District of Columbia, the U.S. Virgin Islands, and six major urban areas.

According to the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (2018 Aug 24;67[33]:909-17), HPV vaccination continues to lag behind Tdap and MCV in 2018. Among all adolescents, coverage with one or more doses of HPV was 66%, with up-to-date HPV status in 49%. In contrast, 82% received a dose of MCV, and 89% received a dose of Tdap.

Coverage for receiving one or more doses of HPV among females was 69%, and up-to-date HPV status was 53%; among males, coverage with one or more doses was 63%, and up-to-date HPV status was 44%.

Up-to-date HPV coverage status differed geographically, ranging from 29% in Mississippi to 78% in DC. Overall, eight states and the District of Columbia reported increases in up-to-date status (District of Columbia, Louisiana, Massachusetts, Nebraska, North Carolina, South Carolina, Texas, Vermont, and Virginia). Kudos to Virginia for having the largest increase (20 percentage points).

Coverage also differed between urban and rural areas: one or more doses at 70% vs. 59% and up-to-date status at 52% vs. 42%.

HPV coverage differed by poverty level as well. It was higher for persons living below the poverty level, with one or more doses in 73% and up-to-date status in 54%, compared with persons living at or above poverty level at 63% and 47%, respectively.
 

HPV-related cancers

The most recent CDC data regarding types of HPV-associated cancers during 2011-2015 suggest that HPV types 16 and 18 account for the majority of cervical (78%) and oropharyngeal (86%) cancers.

Currently, there are more cases of oropharyngeal cancer than cervical, and we have no screening tool for the former.
 

Safety

Safety has been well documented. Since licensure, no serious safety concerns have been identified, contrary to what has been reported on various social and news media outlets. Yet it remains a concern for many parents who have delayed initiation of vaccine. Efficacy also has been documented in the United States and abroad.

Suggestions for improving HPV immunization coverage

Here are eight suggestions to help you recommend the vaccine and convince hesitant parents of its necessity:

1. Focus on your delivery of the HPV immunization recommendation. Clinician recommendation is the No. 1 reason parents vaccinate. The tone you use and how you make the recommendation can affect how the parent perceives the importance of this vaccine. The following are components of a high-quality recommendation (Academic Pediatrics. 2018;18:S23-S27):

• Routinely recommend vaccine at 11-12 years.
• Recommend vaccine for all preteens, not just those you feel are at risk for infection.
• Recommend the vaccine be given the same day it is discussed.
• Use language that expresses the importance of the HPV vaccine.

2. Use the “announcement or presumptive approach.” You expect the parent to agree with your recommendation. You don’t want to convey that it is an option.

3. Remind parents that immunizing on time means only two doses of HPV.

4. Revisit the topic again during another visit if a parent declines. Data suggest secondary acceptance can be as high as 66%.

5. Consider using a motivational interviewing approach for parents who are very hesitant to vaccinate. Most people want to comply with recommended health interventions.

6. Educate your staff about the importance of HPV vaccine and how it prevents cancer.

7. Determine how well your practice immunizes adolescents. This would be a perfect quality improvement project.

8. Explore “Answering Parents’ Questions” and other resources at www.cdc.gov/hpv to find quick answers to HPV vaccine–related questions .

Why is HPV coverage, a vaccine to prevent cancer, still lagging behind Tdap and MCV? I am as puzzled as others. What I do know is this: Our children will mature and one day become sexually active. They can be exposed to and get infected with HPV, and we can’t predict which ones will not clear the virus and end up developing an HPV-related cancer in the future. At the end of the day, HPV vaccination is cancer prevention.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.

Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.

A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.

There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° ± 11.3°) (P = .004) compared with studies from Europe. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

Continue to: Reverse total shoulder arthroplasty...

Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.^1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.^3-5 Al-Hadithy and colleagues⁶ reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues⁷ evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.^3,8,9

The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.^10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.

METHODS

A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.¹² A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).¹³Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine¹⁴) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.

A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).¹⁵

STATISTICAL ANALYSIS

First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.

Continue to: RESULTS...

 

 

RESULTS

There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).

Table 1. Demographic Data by Continent

	North America	Europe	Asia	Australia	Total	P-value
Number of studies	52	43	4	4	103	-
Number of subjects	6158	2609	51	155	8973	-
Level of evidence						0.693
II	5 (10%)	3 (7%)	0 (0%)	0 (0%)	8 (8%)
III	10 (19%)	4 (9%)	0 (0%)	1 (25%)	15 (15%)
IV	37 (71%)	36 (84%)	4 (100%)	3 (75%)	80 (78%)
Mean MCMS	34.6 ± 8.4	40.2 ± 8.0	32.5 12.4	34.5 ± 6.6	36.9 ± 8.7	0.010
Institutional collaboration						1.000
Multi-center	7 (14%)	6 (14%)	0 (0%)	0 (0%)	13 (13%)
Single-center	45 (86%)	37 (86%)	4 (100%)	4 (100%)	90 (87%)
Financial conflict of interest						0.005
Present	28 (54%)	15 (35%)	0 (0%)	0 (0%)	43 (42%)
Not present	19 (37%)	16 (37%)	4 (100%)	4 (100%)	43 (42%)
Not reported	5 (10%)	12 (28%)	0 (0%)	0 (0%)	17 (17%)
Sex						N/A
Male	2157 (38%)	1026 (39%)	13 (25%)	61 (39%)	3257 (38%)
Female	3520 (62%)	1622 (61%)	38 (75%)	94 (61%)	5274 (62%)
Mean age (years)	71.3 ± 5.6	70.1 ± 7.9	68.1 ± 5.3	76.9 ± 3.0	70.9 ± 6.7	0.191
Minimum age (mean across studies)	56.9 ± 12.8	52.8 ± 15.7	62.8 ± 6.2	68.0 ± 12.1	55.6 ± 14.3	0.160
Maximum age (mean across studies)	82.1 ± 8.6	83.0 ± 5.5	73.0 ± 9.4	85.0 ± 7.9	82.2 ± 7.6	0.079
Mean length of follow-up (months)	26.5 ± 13.7	43.1 ± 21.7	29.4 ± 7.9	34.2 ± 16.6	34.3 ± 19.3	<0.001
Prosthesis type						N/A
Cemented	988 (89%)	969 (72%)	0 (0%)	8 (16%)	1965 (78%)
Press fit	120 (11%)	379 (28%)	0 (0%)	41 (84%)	540 (22%)

Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.

 

In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).

Continue to: Rotator cuff tear arthropathy...

 

 

Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).

Table 2. Number (Percent) of Studies With Each Indication by Continent

	North America	Europe	Asia	Australia	Total	P-value
Rotator cuff arthropathy	29 (56%)	19 (44%)	3 (75%)	3 (75%)	54 (52%)	0.390
Osteoarthritis	4 (8%)	10 (23%)	1 (25%)	1 (25%)	16 (16%)	0.072
Rheumatoid arthritis	9 (17%)	10 (23%)	0 (0%)	2 (50%)	21 (20%)	0.278
Post-traumatic arthritis	3 (6%)	5 (12%)	0 (0%)	1 (25%)	9 (9%)	0.358
Instability	6 (12%)	3 (7%)	0 (0%)	1 (25%)	10 (10%)	0.450
Revision of previous RTSA for instability	5 (10%)	1 (2%)	0 (0%)	1 (25%)	7 (7%)	0.192
Infection	4 (8%)	1 (2%)	1 (25%)	0 (0%)	6 (6%)	0.207
Unclassified acute proximal humerus fracture	9 (17%)	5 (12%)	1 (25%)	1 (25%)	16  (16%)	0.443
Acute 2-part proximal humerus fracture	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	N/A
Acute 3-part proximal humerus fracture	2 (4%)	0 (0%)	0 (0%)	0 (0%)	2 (2%)	0.574
Acute 4-part proximal humerus fracture	5 (10%)	0 (0%)	0 (0%)	0 (0%)	5 (5%)	0.183
Acute 3- or 4-part proximal humerus fracture	6 (12%)	2 (5%)	0 (0%)	0 (0%)	8 (8%)	0.635
Revised from previous nonop proximal humerus fracture	7 (13%)	3 (7%)	0 (0%)	0 (0%)	10 (10%)	0.787
Revised from ORIF	1 (2%)	1 (2%)	0 (0%)	0 (0%)	2 (2%)	1.000
Revised from CRPP	0 (0%)	1 (2%)	0 (0%)	0 (0%)	1 (1%)	0.495
Revised from hemi	8 (15%)	4 (9%)	0 (0%)	1 (25%)	13 (13%)	0.528
Revised from TSA	15 (29%)	11 (26%)	0 (0%)	2 (50%)	28 (27%)	0.492
Osteonecrosis	4 (8%)	2 (5%)	1 (25%)	0 (0%)	7 (7%)	0.401
Pseudoparalysis irreparable tear without arthritis	20 (38%)	18 (42%)	2 (50%)	1 (25%)	41 (40%)	0.919
Bone tumors	0 (0%)	4 (9.3%)	0 (0%)	0 (0%)	4 (4%)	0.120
Locked shoulder dislocation	0 (0%)	0 (0%)	1 (25%)	0 (0%)	1 (1%)	0.078

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

 

Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent

	North America	Europe	Asia	Australia	Total
Rotator cuff arthropathy	4418	895	24	122	5459
Osteoarthritis	90	251	1	14	356
Rheumatoid arthritis	59	87	0	2	148
Post-traumatic arthritis	62	136	0	1	199
Instability	23	15	0	1	39
Revision of previous RTSA for instability	29	2	0	1	32
Infection	28	11	2	0	41
Unclassified acute proximal humerus fracture	42	30	4	8	84
Acute 3-part proximal humerus fracture	60	0	0	0	6
Acute 4-part proximal humerus fracture	42	0	0	0	42
Acute 3- or 4-part proximal humerus fracture	92	46	0	0	138
Revised from previous nonop proximal humerus fracture	43	53	0	0	96
Revised from ORIF	3	9	0	0	12
Revised from CRPP	0	3	0	0	3
Revised from hemi	105	51	0	1	157
Revised from TSA	192	246	0	5	443
Osteonecrosis	9	6	1	0	16
Pseudoparalysis irreparable tear without arthritis	535	795	20	2	1352
Bone tumors	0	38	0	0	38
Locked shoulder dislocation	0	0	1	0	1

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

 

The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).

Table 4. Outcomes by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
DASH	1	2	0	0
Preoperative	54.0	62.0 ± 8.5	-	-	0.582
Postoperative	24.0	32.0 ± 2.8	-	-	0.260
Change	-30.0	-30.0 ± 11.3	-	-	1.000
SPADI	2	0	0	0
Preoperative	80.0 ± 4.2	-	-	-	N/A
Postoperative	34.8 ± 1.1	-	-	-	N/A
Change	-45.3 ± 3.2	-	-	-	N/A
Absolute constant	2	27	0	1
Preopeartive	33.0 ± 0.0	28.2 ± 7.1	-	20.0	0.329
Postoperative	54.5 ± 7.8	62.9 ± 9.0	-	65.0	0.432
Change	+21.5 ± 7.8	+34.7 ± 8.0	-	+45.0	0.044
ASES	13	0	2	0
Preoperative	33.2 ± 5.4	-	32.5 ± 3.5	-	0.867
Postoperative	73.9 ± 6.8	-	75.7 ± 10.8	-	0.752
Change	+40.7 ± 6.5	-	+43.2 ± 14.4	-	0.670
UCLA	3	2	1	0
Preoperative	10.1 ± 3.4	11.2 ± 5.7	12.0	-	0.925
Postoperative	24.5 ± 3.1	24.3 ± 3.7	24.0	-	0.991
Change	+14.4 ± 1.6	+13.1 ± 2.0	+12.0	-	0.524
KSS	0	0	2	0
Preopeartive	-	-	38.2 ± 1.1	-	N/A
Postoperative	-	-	72.3 ± 6.0	-	N/A
Change	-	-	+34.1 ± 7.1	-	N/A
SST-12	12	1	0	0
Preoperative	1.9 ± 0.8	1.2	-	-	N/A
Postoperative	7.1 ± 1.5	5.6	-	-	N/A
Change	+5.3 ± 1.2	+4.4	-	-	N/A
SF-12	1	0	0	0
Preoperative	34.5	-	-	-	N/A
Postoperative	38.5	-	-	-	N/A
Change	+4.0	-	-	-	N/A
SSV	0	5	0	0
Preopeartive	-	22.0 ± 7.4	-	-	N/A
Postoperative	-	63.4 ± 7.9	-	-	N/A
Change	-	+41.4 ± 2.1	-	-	N/A
EQ-5D	0	2	0	0
Preoperative	-	0.5 ± 0.2	-	-	N/A
Postoperative	-	0.8 ± 0.1	-	-	N/A
Change	-	+0.3 ± 0.1	-	-	N/A
OOS	1	0	0	0
Preoperative	24.7	-	-	-	N/A
Postoperative	14.9	-	-	-	N/A
Change	-9.9	-	-	-	N/A
Rowe	0	1	0	0
Preoperative	-	50.2	-	-	N/A
Postoperative	-	82.1	-	-	N/A
Change	-	31.9	-	-	N/A
Oxford	0	2	0	0
Preoperative	-	119.9 ± 138.8	-	-	N/A
Postoperative	-	39.9 ± 3.3	-	-	N/A
Change	-	-80.6 ± 142.2	-	-	N/A
Penn	1	0	0	0
Preoperative	24.9	-	-	-	N/A
Postoperative	66.4	-	-	-	N/A
Change	+41.5	-	-	-	N/A
VAS	10	1	1	1
Preoperative	6.6 ± 0.8	7.0	8.4	7.0	N/A
Postoperative	2.0 ± 0.7	1.0	0.8	0.8	N/A
Change	-4.6 ± 0.8	-6.0	-7.6	-6.2	N/A
SF-36 physical	2	0	0	0
Preoperative	32.7 ± 1.2	-	-	-	N/A
Postoperative	39.6 ± 4.0	-	-	-	N/A
Change	+7.0 ± 2.8	-	-	-	N/A
SF-36 mental	2	0	0	0
Preoperative	43.6 ± 2.8	-	-	-	N/A
Postoperative	48.1 ± 1.0	-	-	-	N/A
Change	+4.5 ± 1.8	-	-	-	N/A

Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.

 

Table 5. Shoulder Range of Motion, by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
Flexion	18	22	1	1
Preoperative	57.6 ± 17.9	65.5 ± 17.2	91.0	30.0	0.060
Postoperative	126.6 ± 14.4	121.8 ± 19.0	133.0	150.0	0.360
Change	+69.0 ± 24.5	+56.3 ± 11.3	+42.0	120.0	0.004
Abduction	11	12	1	0
Preoperative	53.7 ± 25.0	52.0 ± 19.0	88.0	-	0.311
Postoperative	109.3 ± 15.1	105.4 ± 19.8	131.0	-	0.386
Change	55.5 ± 25.5	53.3 ± 8.3	43.0	-	0.804
External rotation	17	19	0	0
Preoperative	19.4 ± 9.9	11.2 ± 6.1	-	-	0.005
Postoperative	34.1 ± 13.3	19.3 ± 8.9	-	-	<0.001
Change	+14.7 ± 13.2	+8.1 ± 8.5	-	-	0.079

Continue to: DISCUSSION...

 

 

DISCUSSION

RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.

RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.¹⁰ This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.¹¹ Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.^16,17 Frankle and colleagues¹⁶ evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues¹⁷ evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).

It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.¹⁸ Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.¹⁹ However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.²⁰

Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.^6,21,22

One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.²³ This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.^24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.²⁶ However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.²⁷ With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.

LIMITATIONS

Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.

CONCLUSION

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

This paper will be judged for the Resident Writer’s Award.

Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.

A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.

There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° ± 11.3°) (P = .004) compared with studies from Europe. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

Continue to: Reverse total shoulder arthroplasty...

Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.^1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.^3-5 Al-Hadithy and colleagues⁶ reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues⁷ evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.^3,8,9

The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.^10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.

METHODS

A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.¹² A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).¹³Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine¹⁴) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.

A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).¹⁵

STATISTICAL ANALYSIS

First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.

Continue to: RESULTS...

 

 

RESULTS

There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).

Table 1. Demographic Data by Continent

	North America	Europe	Asia	Australia	Total	P-value
Number of studies	52	43	4	4	103	-
Number of subjects	6158	2609	51	155	8973	-
Level of evidence						0.693
II	5 (10%)	3 (7%)	0 (0%)	0 (0%)	8 (8%)
III	10 (19%)	4 (9%)	0 (0%)	1 (25%)	15 (15%)
IV	37 (71%)	36 (84%)	4 (100%)	3 (75%)	80 (78%)
Mean MCMS	34.6 ± 8.4	40.2 ± 8.0	32.5 12.4	34.5 ± 6.6	36.9 ± 8.7	0.010
Institutional collaboration						1.000
Multi-center	7 (14%)	6 (14%)	0 (0%)	0 (0%)	13 (13%)
Single-center	45 (86%)	37 (86%)	4 (100%)	4 (100%)	90 (87%)
Financial conflict of interest						0.005
Present	28 (54%)	15 (35%)	0 (0%)	0 (0%)	43 (42%)
Not present	19 (37%)	16 (37%)	4 (100%)	4 (100%)	43 (42%)
Not reported	5 (10%)	12 (28%)	0 (0%)	0 (0%)	17 (17%)
Sex						N/A
Male	2157 (38%)	1026 (39%)	13 (25%)	61 (39%)	3257 (38%)
Female	3520 (62%)	1622 (61%)	38 (75%)	94 (61%)	5274 (62%)
Mean age (years)	71.3 ± 5.6	70.1 ± 7.9	68.1 ± 5.3	76.9 ± 3.0	70.9 ± 6.7	0.191
Minimum age (mean across studies)	56.9 ± 12.8	52.8 ± 15.7	62.8 ± 6.2	68.0 ± 12.1	55.6 ± 14.3	0.160
Maximum age (mean across studies)	82.1 ± 8.6	83.0 ± 5.5	73.0 ± 9.4	85.0 ± 7.9	82.2 ± 7.6	0.079
Mean length of follow-up (months)	26.5 ± 13.7	43.1 ± 21.7	29.4 ± 7.9	34.2 ± 16.6	34.3 ± 19.3	<0.001
Prosthesis type						N/A
Cemented	988 (89%)	969 (72%)	0 (0%)	8 (16%)	1965 (78%)
Press fit	120 (11%)	379 (28%)	0 (0%)	41 (84%)	540 (22%)

Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.

 

In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).

Continue to: Rotator cuff tear arthropathy...

 

 

Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).

Table 2. Number (Percent) of Studies With Each Indication by Continent

	North America	Europe	Asia	Australia	Total	P-value
Rotator cuff arthropathy	29 (56%)	19 (44%)	3 (75%)	3 (75%)	54 (52%)	0.390
Osteoarthritis	4 (8%)	10 (23%)	1 (25%)	1 (25%)	16 (16%)	0.072
Rheumatoid arthritis	9 (17%)	10 (23%)	0 (0%)	2 (50%)	21 (20%)	0.278
Post-traumatic arthritis	3 (6%)	5 (12%)	0 (0%)	1 (25%)	9 (9%)	0.358
Instability	6 (12%)	3 (7%)	0 (0%)	1 (25%)	10 (10%)	0.450
Revision of previous RTSA for instability	5 (10%)	1 (2%)	0 (0%)	1 (25%)	7 (7%)	0.192
Infection	4 (8%)	1 (2%)	1 (25%)	0 (0%)	6 (6%)	0.207
Unclassified acute proximal humerus fracture	9 (17%)	5 (12%)	1 (25%)	1 (25%)	16  (16%)	0.443
Acute 2-part proximal humerus fracture	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	N/A
Acute 3-part proximal humerus fracture	2 (4%)	0 (0%)	0 (0%)	0 (0%)	2 (2%)	0.574
Acute 4-part proximal humerus fracture	5 (10%)	0 (0%)	0 (0%)	0 (0%)	5 (5%)	0.183
Acute 3- or 4-part proximal humerus fracture	6 (12%)	2 (5%)	0 (0%)	0 (0%)	8 (8%)	0.635
Revised from previous nonop proximal humerus fracture	7 (13%)	3 (7%)	0 (0%)	0 (0%)	10 (10%)	0.787
Revised from ORIF	1 (2%)	1 (2%)	0 (0%)	0 (0%)	2 (2%)	1.000
Revised from CRPP	0 (0%)	1 (2%)	0 (0%)	0 (0%)	1 (1%)	0.495
Revised from hemi	8 (15%)	4 (9%)	0 (0%)	1 (25%)	13 (13%)	0.528
Revised from TSA	15 (29%)	11 (26%)	0 (0%)	2 (50%)	28 (27%)	0.492
Osteonecrosis	4 (8%)	2 (5%)	1 (25%)	0 (0%)	7 (7%)	0.401
Pseudoparalysis irreparable tear without arthritis	20 (38%)	18 (42%)	2 (50%)	1 (25%)	41 (40%)	0.919
Bone tumors	0 (0%)	4 (9.3%)	0 (0%)	0 (0%)	4 (4%)	0.120
Locked shoulder dislocation	0 (0%)	0 (0%)	1 (25%)	0 (0%)	1 (1%)	0.078

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

 

Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent

	North America	Europe	Asia	Australia	Total
Rotator cuff arthropathy	4418	895	24	122	5459
Osteoarthritis	90	251	1	14	356
Rheumatoid arthritis	59	87	0	2	148
Post-traumatic arthritis	62	136	0	1	199
Instability	23	15	0	1	39
Revision of previous RTSA for instability	29	2	0	1	32
Infection	28	11	2	0	41
Unclassified acute proximal humerus fracture	42	30	4	8	84
Acute 3-part proximal humerus fracture	60	0	0	0	6
Acute 4-part proximal humerus fracture	42	0	0	0	42
Acute 3- or 4-part proximal humerus fracture	92	46	0	0	138
Revised from previous nonop proximal humerus fracture	43	53	0	0	96
Revised from ORIF	3	9	0	0	12
Revised from CRPP	0	3	0	0	3
Revised from hemi	105	51	0	1	157
Revised from TSA	192	246	0	5	443
Osteonecrosis	9	6	1	0	16
Pseudoparalysis irreparable tear without arthritis	535	795	20	2	1352
Bone tumors	0	38	0	0	38
Locked shoulder dislocation	0	0	1	0	1

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

 

The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).

Table 4. Outcomes by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
DASH	1	2	0	0
Preoperative	54.0	62.0 ± 8.5	-	-	0.582
Postoperative	24.0	32.0 ± 2.8	-	-	0.260
Change	-30.0	-30.0 ± 11.3	-	-	1.000
SPADI	2	0	0	0
Preoperative	80.0 ± 4.2	-	-	-	N/A
Postoperative	34.8 ± 1.1	-	-	-	N/A
Change	-45.3 ± 3.2	-	-	-	N/A
Absolute constant	2	27	0	1
Preopeartive	33.0 ± 0.0	28.2 ± 7.1	-	20.0	0.329
Postoperative	54.5 ± 7.8	62.9 ± 9.0	-	65.0	0.432
Change	+21.5 ± 7.8	+34.7 ± 8.0	-	+45.0	0.044
ASES	13	0	2	0
Preoperative	33.2 ± 5.4	-	32.5 ± 3.5	-	0.867
Postoperative	73.9 ± 6.8	-	75.7 ± 10.8	-	0.752
Change	+40.7 ± 6.5	-	+43.2 ± 14.4	-	0.670
UCLA	3	2	1	0
Preoperative	10.1 ± 3.4	11.2 ± 5.7	12.0	-	0.925
Postoperative	24.5 ± 3.1	24.3 ± 3.7	24.0	-	0.991
Change	+14.4 ± 1.6	+13.1 ± 2.0	+12.0	-	0.524
KSS	0	0	2	0
Preopeartive	-	-	38.2 ± 1.1	-	N/A
Postoperative	-	-	72.3 ± 6.0	-	N/A
Change	-	-	+34.1 ± 7.1	-	N/A
SST-12	12	1	0	0
Preoperative	1.9 ± 0.8	1.2	-	-	N/A
Postoperative	7.1 ± 1.5	5.6	-	-	N/A
Change	+5.3 ± 1.2	+4.4	-	-	N/A
SF-12	1	0	0	0
Preoperative	34.5	-	-	-	N/A
Postoperative	38.5	-	-	-	N/A
Change	+4.0	-	-	-	N/A
SSV	0	5	0	0
Preopeartive	-	22.0 ± 7.4	-	-	N/A
Postoperative	-	63.4 ± 7.9	-	-	N/A
Change	-	+41.4 ± 2.1	-	-	N/A
EQ-5D	0	2	0	0
Preoperative	-	0.5 ± 0.2	-	-	N/A
Postoperative	-	0.8 ± 0.1	-	-	N/A
Change	-	+0.3 ± 0.1	-	-	N/A
OOS	1	0	0	0
Preoperative	24.7	-	-	-	N/A
Postoperative	14.9	-	-	-	N/A
Change	-9.9	-	-	-	N/A
Rowe	0	1	0	0
Preoperative	-	50.2	-	-	N/A
Postoperative	-	82.1	-	-	N/A
Change	-	31.9	-	-	N/A
Oxford	0	2	0	0
Preoperative	-	119.9 ± 138.8	-	-	N/A
Postoperative	-	39.9 ± 3.3	-	-	N/A
Change	-	-80.6 ± 142.2	-	-	N/A
Penn	1	0	0	0
Preoperative	24.9	-	-	-	N/A
Postoperative	66.4	-	-	-	N/A
Change	+41.5	-	-	-	N/A
VAS	10	1	1	1
Preoperative	6.6 ± 0.8	7.0	8.4	7.0	N/A
Postoperative	2.0 ± 0.7	1.0	0.8	0.8	N/A
Change	-4.6 ± 0.8	-6.0	-7.6	-6.2	N/A
SF-36 physical	2	0	0	0
Preoperative	32.7 ± 1.2	-	-	-	N/A
Postoperative	39.6 ± 4.0	-	-	-	N/A
Change	+7.0 ± 2.8	-	-	-	N/A
SF-36 mental	2	0	0	0
Preoperative	43.6 ± 2.8	-	-	-	N/A
Postoperative	48.1 ± 1.0	-	-	-	N/A
Change	+4.5 ± 1.8	-	-	-	N/A

Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.

 

Table 5. Shoulder Range of Motion, by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
Flexion	18	22	1	1
Preoperative	57.6 ± 17.9	65.5 ± 17.2	91.0	30.0	0.060
Postoperative	126.6 ± 14.4	121.8 ± 19.0	133.0	150.0	0.360
Change	+69.0 ± 24.5	+56.3 ± 11.3	+42.0	120.0	0.004
Abduction	11	12	1	0
Preoperative	53.7 ± 25.0	52.0 ± 19.0	88.0	-	0.311
Postoperative	109.3 ± 15.1	105.4 ± 19.8	131.0	-	0.386
Change	55.5 ± 25.5	53.3 ± 8.3	43.0	-	0.804
External rotation	17	19	0	0
Preoperative	19.4 ± 9.9	11.2 ± 6.1	-	-	0.005
Postoperative	34.1 ± 13.3	19.3 ± 8.9	-	-	<0.001
Change	+14.7 ± 13.2	+8.1 ± 8.5	-	-	0.079

Continue to: DISCUSSION...

 

 

DISCUSSION

RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.

RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.¹⁰ This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.¹¹ Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.^16,17 Frankle and colleagues¹⁶ evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues¹⁷ evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).

It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.¹⁸ Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.¹⁹ However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.²⁰

Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.^6,21,22

One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.²³ This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.^24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.²⁶ However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.²⁷ With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.

LIMITATIONS

Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.

CONCLUSION

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

This paper will be judged for the Resident Writer’s Award.

Reverse total shoulder arthroplasty (RTSA) is a common treatment for rotator cuff tear arthropathy. We performed a systematic review of all the RTSA literature to answer if we are treating the same patients with RTSA, across the world.

A systematic review was registered with PROSPERO, the international prospective register of systematic reviews, and performed with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting RTSA outcomes with levels of evidence I to IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents. Statistical comparisons were conducted using linear regression, analysis of variance (ANOVA), Fisher's exact test, and Pearson's chi-square test.

There were 103 studies included in the analysis (8973 patients; 62% female; mean age, 70.9 ± 6.7 years; mean length of follow-up, 34.3 ± 19.3 months) that had a low Modified Coleman Methodology Score (MCMS) (mean, 36.9 ± 8.7: poor). Most patients (60.8%) underwent RTSA for a diagnosis of rotator cuff arthropathy, whereas 1% underwent RTSA for fracture; indications varied by continent. There were no consistent reports of preopeartive or postoperative scores from studies in any region. Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° ± 11.3°) (P = .004) compared with studies from Europe. North America had the greatest total number of publications followed by Europe. The total yearly number of publications increased each year (P < .001), whereas the MCMS decreased each year (P = .037).

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent, although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

Continue to: Reverse total shoulder arthroplasty...

Reverse total shoulder arthroplasty (RTSA) is a common procedure with indications including rotator cuff tear arthropathy, proximal humerus fractures, and others.^1,2 Studies have shown excellent, reliable, short- and mid-term outcomes in patients treated with RTSA for various indications.^3-5 Al-Hadithy and colleagues⁶ reviewed 41 patients who underwent RTSA for pseudoparalysis secondary to rotator cuff tear arthropathy and, at a mean follow-up of 5 years, found significant improvements in range of motion (ROM) as well as age-adjusted Constant and Oxford Outcome scores. Similarly, Ross and colleagues⁷ evaluated outcomes of RTSA in 28 patients in whom RTSA was performed for 3- or 4-part proximal humerus fractures, and found both good clinical and radiographic outcomes with no revision surgeries at a mean follow-up of 54.9 months. RTSA is performed across the world, with specific implant designs, specifically humeral head inclination, but is more common in some areas when compared with others.^3,8,9

The number of RTSAs performed has steadily increased over the past 20 years, with recent estimates of approximately 20,000 RTSAs performed in the United States in 2011.^10,11 However, there is little information about the similarities and differences between those patients undergoing RTSA in various parts of the world regarding surgical indications, patient demographics, and outcomes. The purpose of this study is to perform a systematic review and meta-analysis of the RTSA body of literature to both identify and compare characteristics of studies published (level of evidence, whether a conflict of interest existed), patients analyzed (age, gender), and surgical indications performed across both continents and countries. Essentially, the study aims to answer the question, "Across the world, are we treating the same patients?" The authors hypothesized that there would be no significant differences in RTSA publications, subjects, and indications based on both the continent and country of publication.

METHODS

A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using a PRISMA checklist.¹² A systematic review registration was performed using PROSPERO, the international prospective register of systematic reviews (registration number CRD42014010578).¹³Two reviewers independently conducted the search on March 25, 2014, using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I to IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine¹⁴) clinical studies were eligible. Medical conference abstracts were ineligible for inclusion. All references within included studies were cross-referenced for inclusion if missed by the initial search with any additionally located studies screened for inclusion. Duplicate subject publications within separate unique studies were not reported twice, but rather the study with longer duration follow-up or, if follow-up was equal, the study with the greater number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical and cadaver studies, total shoulder arthroplasty (TSA) papers, arthroscopic shoulder surgery papers, imaging, surgical techniques, and classification studies were excluded.

A total of 255 studies were identified, and, after implementation of the exclusion criteria, 103 studies were included in the final analysis (Figure 1). Subjects of interest in this systematic review underwent RTSA for one of many indications including rotator cuff tear arthropathy, osteoarthritis, rheumatoid arthritis, posttraumatic arthritis, instability, revision from a previous RTSA for instability, infection, acute proximal humerus fracture, revision from a prior proximal humerus fracture, revision from a prior hemiarthroplasty, revision from a prior TSA, osteonecrosis, pseudoparalysis, tumor, and a locked shoulder dislocation. There was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, body mass index, diagnoses treated, and surgical positioning. Clinical outcome scores sought were the DASH (Disability of the Arm, Shoulder, and Hand), SPADI (Shoulder Pain And Disability Index), Absolute Constant, ASES (American Shoulder and Elbow Score), KSS (Korean Shoulder Score), SST-12 (Simple Shoulder Test), SF-12 (12-item Short Form), SF-36 (36-item Short Form), SSV (Subjective Shoulder Value), EQ-5D (EuroQol-5 Dimension), SANE (Single Assessment Numeric Evaluation), Rowe Score for Instability, Oxford Instability Score, UCLA (University of California, Los Angeles) activity score, Penn Shoulder Score, and VAS (visual analog scale). In addition, ROM (forward elevation, abduction, external rotation, internal rotation) was analyzed. Radiographs and magnetic resonance imaging data were extracted when available. The methodological quality of the study was evaluated using the MCMS (Modified Coleman Methodology Score).¹⁵

STATISTICAL ANALYSIS

First, the number of publications per year, level of evidence, and Modified Coleman Methodology Score were tested for association with the calendar year using linear regression. Second, demographic data were tested for association with the continent using Pearson’s chi-square test or ANOVA. Third, indications were tested for association with the continent using Fisher’s exact test. Finally, clinical outcome scores and ROM were tested for association with the continent using ANOVA. Statistical significance was extracted from studies when available. Statistical significance was defined as P < .05.

Continue to: RESULTS...

 

 

RESULTS

There were 103 studies included in the analysis (Figure 1). A total of 8973 patients were included, 62% of whom were female with a mean age of 70.9 ± 6.7 years (Table 1). The average follow-up was 34.3 ± 19.3 months. North America had the overall greatest total number of publications on RTSA, followed by Europe (Figure 2). The total yearly number of publications increased by a mean of 1.95 publications each year (P < .001). There was no association between the mean level of evidence with the year of publication (P = .296) (Figure 3). Overall, the rating of studies was poor for the MCMS (mean 36.9 ± 8.7). The MCMS decreased each year by a mean of 0.76 points (P = .037) (Figure 4).

Table 1. Demographic Data by Continent

	North America	Europe	Asia	Australia	Total	P-value
Number of studies	52	43	4	4	103	-
Number of subjects	6158	2609	51	155	8973	-
Level of evidence						0.693
II	5 (10%)	3 (7%)	0 (0%)	0 (0%)	8 (8%)
III	10 (19%)	4 (9%)	0 (0%)	1 (25%)	15 (15%)
IV	37 (71%)	36 (84%)	4 (100%)	3 (75%)	80 (78%)
Mean MCMS	34.6 ± 8.4	40.2 ± 8.0	32.5 12.4	34.5 ± 6.6	36.9 ± 8.7	0.010
Institutional collaboration						1.000
Multi-center	7 (14%)	6 (14%)	0 (0%)	0 (0%)	13 (13%)
Single-center	45 (86%)	37 (86%)	4 (100%)	4 (100%)	90 (87%)
Financial conflict of interest						0.005
Present	28 (54%)	15 (35%)	0 (0%)	0 (0%)	43 (42%)
Not present	19 (37%)	16 (37%)	4 (100%)	4 (100%)	43 (42%)
Not reported	5 (10%)	12 (28%)	0 (0%)	0 (0%)	17 (17%)
Sex						N/A
Male	2157 (38%)	1026 (39%)	13 (25%)	61 (39%)	3257 (38%)
Female	3520 (62%)	1622 (61%)	38 (75%)	94 (61%)	5274 (62%)
Mean age (years)	71.3 ± 5.6	70.1 ± 7.9	68.1 ± 5.3	76.9 ± 3.0	70.9 ± 6.7	0.191
Minimum age (mean across studies)	56.9 ± 12.8	52.8 ± 15.7	62.8 ± 6.2	68.0 ± 12.1	55.6 ± 14.3	0.160
Maximum age (mean across studies)	82.1 ± 8.6	83.0 ± 5.5	73.0 ± 9.4	85.0 ± 7.9	82.2 ± 7.6	0.079
Mean length of follow-up (months)	26.5 ± 13.7	43.1 ± 21.7	29.4 ± 7.9	34.2 ± 16.6	34.3 ± 19.3	<0.001
Prosthesis type						N/A
Cemented	988 (89%)	969 (72%)	0 (0%)	8 (16%)	1965 (78%)
Press fit	120 (11%)	379 (28%)	0 (0%)	41 (84%)	540 (22%)

Abbreviations: MCMS, Modified Coleman Methodology Score; N/A, not available.

 

In studies that reported press-fit vs cemented prostheses, the highest percentage of press-fit prostheses compared with cemented prostheses was seen in Australia (84% press-fit), whereas the highest percentage of cemented prostheses was seen in North America (89% cemented). A higher percentage of studies from North America had a financial conflict of interest (COI) than did those from other countries (54% had a COI).

Continue to: Rotator cuff tear arthropathy...

 

 

Rotator cuff tear arthropathy was the most common indication for RTSA overall in 5459 patients, followed by pseudoparalysis in 1352 patients (Tables 2 and 3). While studies in North America reported rotator cuff tear arthropathy as the indication for RTSA in 4418 (75.8%) patients, and pseudoparalysis as the next most common indication in 535 (9.2%) patients, studies from Europe reported rotator cuff tear arthropathy as the indication in 895 (33.5%) patients, and pseudoparalysis as the indication in 795 (29.7%) patients. Studies from Asia also had a relatively even split between rotator cuff tear arthropathy and pseudoparalysis (45.3% vs 37.8%), whereas those from Australia were mostly rotator cuff tear arthropathy (77.7%).

Table 2. Number (Percent) of Studies With Each Indication by Continent

	North America	Europe	Asia	Australia	Total	P-value
Rotator cuff arthropathy	29 (56%)	19 (44%)	3 (75%)	3 (75%)	54 (52%)	0.390
Osteoarthritis	4 (8%)	10 (23%)	1 (25%)	1 (25%)	16 (16%)	0.072
Rheumatoid arthritis	9 (17%)	10 (23%)	0 (0%)	2 (50%)	21 (20%)	0.278
Post-traumatic arthritis	3 (6%)	5 (12%)	0 (0%)	1 (25%)	9 (9%)	0.358
Instability	6 (12%)	3 (7%)	0 (0%)	1 (25%)	10 (10%)	0.450
Revision of previous RTSA for instability	5 (10%)	1 (2%)	0 (0%)	1 (25%)	7 (7%)	0.192
Infection	4 (8%)	1 (2%)	1 (25%)	0 (0%)	6 (6%)	0.207
Unclassified acute proximal humerus fracture	9 (17%)	5 (12%)	1 (25%)	1 (25%)	16  (16%)	0.443
Acute 2-part proximal humerus fracture	0 (0%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	N/A
Acute 3-part proximal humerus fracture	2 (4%)	0 (0%)	0 (0%)	0 (0%)	2 (2%)	0.574
Acute 4-part proximal humerus fracture	5 (10%)	0 (0%)	0 (0%)	0 (0%)	5 (5%)	0.183
Acute 3- or 4-part proximal humerus fracture	6 (12%)	2 (5%)	0 (0%)	0 (0%)	8 (8%)	0.635
Revised from previous nonop proximal humerus fracture	7 (13%)	3 (7%)	0 (0%)	0 (0%)	10 (10%)	0.787
Revised from ORIF	1 (2%)	1 (2%)	0 (0%)	0 (0%)	2 (2%)	1.000
Revised from CRPP	0 (0%)	1 (2%)	0 (0%)	0 (0%)	1 (1%)	0.495
Revised from hemi	8 (15%)	4 (9%)	0 (0%)	1 (25%)	13 (13%)	0.528
Revised from TSA	15 (29%)	11 (26%)	0 (0%)	2 (50%)	28 (27%)	0.492
Osteonecrosis	4 (8%)	2 (5%)	1 (25%)	0 (0%)	7 (7%)	0.401
Pseudoparalysis irreparable tear without arthritis	20 (38%)	18 (42%)	2 (50%)	1 (25%)	41 (40%)	0.919
Bone tumors	0 (0%)	4 (9.3%)	0 (0%)	0 (0%)	4 (4%)	0.120
Locked shoulder dislocation	0 (0%)	0 (0%)	1 (25%)	0 (0%)	1 (1%)	0.078

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

 

Table 3. Number of Patients With Each Indication as Reported by Individual Studies by Continent

	North America	Europe	Asia	Australia	Total
Rotator cuff arthropathy	4418	895	24	122	5459
Osteoarthritis	90	251	1	14	356
Rheumatoid arthritis	59	87	0	2	148
Post-traumatic arthritis	62	136	0	1	199
Instability	23	15	0	1	39
Revision of previous RTSA for instability	29	2	0	1	32
Infection	28	11	2	0	41
Unclassified acute proximal humerus fracture	42	30	4	8	84
Acute 3-part proximal humerus fracture	60	0	0	0	6
Acute 4-part proximal humerus fracture	42	0	0	0	42
Acute 3- or 4-part proximal humerus fracture	92	46	0	0	138
Revised from previous nonop proximal humerus fracture	43	53	0	0	96
Revised from ORIF	3	9	0	0	12
Revised from CRPP	0	3	0	0	3
Revised from hemi	105	51	0	1	157
Revised from TSA	192	246	0	5	443
Osteonecrosis	9	6	1	0	16
Pseudoparalysis irreparable tear without arthritis	535	795	20	2	1352
Bone tumors	0	38	0	0	38
Locked shoulder dislocation	0	0	1	0	1

Abbreviations: CRPP, closed reduction and percutaneous pinning; ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty.

 

The ASES, SST-12, and VAS scores were the most frequently reported outcome scores in studies from North America, whereas the Absolute Constant score was the most common score reported in studies from Europe (Table 4). Studies from North America reported significantly higher postoperative external rotation (34.1° ± 13.3° vs 19.3° ± 8.9°) (P < .001) and a greater change in flexion (69.0° ± 24.5° vs 56.3° +/- 11.3°) (P = .004) compared with studies from Europe (Table 5).

Table 4. Outcomes by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
DASH	1	2	0	0
Preoperative	54.0	62.0 ± 8.5	-	-	0.582
Postoperative	24.0	32.0 ± 2.8	-	-	0.260
Change	-30.0	-30.0 ± 11.3	-	-	1.000
SPADI	2	0	0	0
Preoperative	80.0 ± 4.2	-	-	-	N/A
Postoperative	34.8 ± 1.1	-	-	-	N/A
Change	-45.3 ± 3.2	-	-	-	N/A
Absolute constant	2	27	0	1
Preopeartive	33.0 ± 0.0	28.2 ± 7.1	-	20.0	0.329
Postoperative	54.5 ± 7.8	62.9 ± 9.0	-	65.0	0.432
Change	+21.5 ± 7.8	+34.7 ± 8.0	-	+45.0	0.044
ASES	13	0	2	0
Preoperative	33.2 ± 5.4	-	32.5 ± 3.5	-	0.867
Postoperative	73.9 ± 6.8	-	75.7 ± 10.8	-	0.752
Change	+40.7 ± 6.5	-	+43.2 ± 14.4	-	0.670
UCLA	3	2	1	0
Preoperative	10.1 ± 3.4	11.2 ± 5.7	12.0	-	0.925
Postoperative	24.5 ± 3.1	24.3 ± 3.7	24.0	-	0.991
Change	+14.4 ± 1.6	+13.1 ± 2.0	+12.0	-	0.524
KSS	0	0	2	0
Preopeartive	-	-	38.2 ± 1.1	-	N/A
Postoperative	-	-	72.3 ± 6.0	-	N/A
Change	-	-	+34.1 ± 7.1	-	N/A
SST-12	12	1	0	0
Preoperative	1.9 ± 0.8	1.2	-	-	N/A
Postoperative	7.1 ± 1.5	5.6	-	-	N/A
Change	+5.3 ± 1.2	+4.4	-	-	N/A
SF-12	1	0	0	0
Preoperative	34.5	-	-	-	N/A
Postoperative	38.5	-	-	-	N/A
Change	+4.0	-	-	-	N/A
SSV	0	5	0	0
Preopeartive	-	22.0 ± 7.4	-	-	N/A
Postoperative	-	63.4 ± 7.9	-	-	N/A
Change	-	+41.4 ± 2.1	-	-	N/A
EQ-5D	0	2	0	0
Preoperative	-	0.5 ± 0.2	-	-	N/A
Postoperative	-	0.8 ± 0.1	-	-	N/A
Change	-	+0.3 ± 0.1	-	-	N/A
OOS	1	0	0	0
Preoperative	24.7	-	-	-	N/A
Postoperative	14.9	-	-	-	N/A
Change	-9.9	-	-	-	N/A
Rowe	0	1	0	0
Preoperative	-	50.2	-	-	N/A
Postoperative	-	82.1	-	-	N/A
Change	-	31.9	-	-	N/A
Oxford	0	2	0	0
Preoperative	-	119.9 ± 138.8	-	-	N/A
Postoperative	-	39.9 ± 3.3	-	-	N/A
Change	-	-80.6 ± 142.2	-	-	N/A
Penn	1	0	0	0
Preoperative	24.9	-	-	-	N/A
Postoperative	66.4	-	-	-	N/A
Change	+41.5	-	-	-	N/A
VAS	10	1	1	1
Preoperative	6.6 ± 0.8	7.0	8.4	7.0	N/A
Postoperative	2.0 ± 0.7	1.0	0.8	0.8	N/A
Change	-4.6 ± 0.8	-6.0	-7.6	-6.2	N/A
SF-36 physical	2	0	0	0
Preoperative	32.7 ± 1.2	-	-	-	N/A
Postoperative	39.6 ± 4.0	-	-	-	N/A
Change	+7.0 ± 2.8	-	-	-	N/A
SF-36 mental	2	0	0	0
Preoperative	43.6 ± 2.8	-	-	-	N/A
Postoperative	48.1 ± 1.0	-	-	-	N/A
Change	+4.5 ± 1.8	-	-	-	N/A

Abbreviations: ASES, American Shoulder and Elbow Surgeon score; DASH, Disability of the Arm, Shoulder, and Hand; EQ-5D, EuroQol-5 Dimension; KSS, Korean Shoulder Scoring system; N/A, not available; OOS, Orthopaedic Outcome Score; SF, short form; SPADI, Shoulder Pain and Disability Index; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; UCLA, University of California, Los Angeles; VAS, visual analog scale.

 

Table 5. Shoulder Range of Motion, by Continent

Metric (number of studies)	North America	Europe	Asia	Australia	P-value
Flexion	18	22	1	1
Preoperative	57.6 ± 17.9	65.5 ± 17.2	91.0	30.0	0.060
Postoperative	126.6 ± 14.4	121.8 ± 19.0	133.0	150.0	0.360
Change	+69.0 ± 24.5	+56.3 ± 11.3	+42.0	120.0	0.004
Abduction	11	12	1	0
Preoperative	53.7 ± 25.0	52.0 ± 19.0	88.0	-	0.311
Postoperative	109.3 ± 15.1	105.4 ± 19.8	131.0	-	0.386
Change	55.5 ± 25.5	53.3 ± 8.3	43.0	-	0.804
External rotation	17	19	0	0
Preoperative	19.4 ± 9.9	11.2 ± 6.1	-	-	0.005
Postoperative	34.1 ± 13.3	19.3 ± 8.9	-	-	<0.001
Change	+14.7 ± 13.2	+8.1 ± 8.5	-	-	0.079

Continue to: DISCUSSION...

 

 

DISCUSSION

RTSA is a common procedure performed in many different areas of the world for a variety of indications. The study hypotheses were partially confirmed, as there were no significant differences seen in the characteristics of the studies published and patients analyzed; although, the majority of studies from North America reported rotator cuff tear arthropathy as the primary indication for RTSA, whereas studies from Europe were split between rotator cuff tear arthropathy and pseudoparalysis as the primary indication. Hence, based on the current literature the study proved that we are treating the same patients. Despite this finding, we may be treating them for different reasons with an RTSA.

RTSA has become a standard procedure in the United States, with >20,000 RTSAs performed in 2011.¹⁰ This number will continue to increase as it has over the past 20 years given the aging population in the United States, as well as the expanding indications for RTSA.¹¹ Indications of RTSA have become broad, although the main indication remains as rotator cuff tear arthropathy (>60% of all patients included in this study), and pseudoparalysis (>15% of all patients included in this study). Results for RTSA for rotator cuff tear arthropathy and pseudoparalysis have been encouraging.^16,17 Frankle and colleagues¹⁶ evaluated 60 patients who underwent RTSA for rotator cuff tear arthropathy at a minimum of 2 years follow-up (average, 33 months). The authors found significant improvements in all measured clinical outcome variables (P < .0001) (ASES, mean function score, mean pain score, and VAS) as well as ROM, specifically forward flexion increased from 55° to 105.1°, and abduction increased from 41.4° to 101.8°. Similarly, Werner and colleagues¹⁷ evaluated 58 consecutive patients who underwent RTSA for pseudoparalysis secondary to irreparable rotator cuff dysfunction at a mean follow-up of 38 months. Overall, significant improvements (P < .0001) were seen in the SSV score, relative Constant score, and Constant score for pain, active anterior elevation (42° to 100° following RTSA), and active abduction (43° to 90° following RTSA).

It is essential to understand the similarities and differences between patients undergoing RTSA in different parts of the world so the literature from various countries can be compared between regions, and conclusions extrapolated to the correct patients. For example, an interesting finding in this study is that the majority of patients in North America have their prosthesis cemented whereas the majority of patients in Australia have their prosthesis press-fit. While the patients each continent is treating are not significantly different (mostly older women), the difference in surgical technique could have implications in long- or short-term functional outcomes. Prior studies have shown no difference in axial micromotion between cemented and press-fit humeral components, but the clinical implications surrounding this are not well defined.¹⁸ Small series comparing cementless to cemented humeral prosthesis in RTSA have found no significant differences in clinical outcomes or postoperative ROM, but larger series are necessary to validate these outcomes.¹⁹ However, studies have shown lower rates of postoperative infections in patients who receive antibiotic-loaded cement compared with those who receive plain bone cement following RTSA.²⁰

Similarly, as the vast majority of patients in North America had an RTSA for rotator cuff arthropathy (75.8%) whereas those from Europe had RTSA almost equally for rotator cuff arthropathy (33.5%) and pseudoparalysis (29.7%), one must ensure similar patient populations before attempting to extrapolate results of a study from a different country to patients in other areas. Fortunately, the clinical results following RTSA for either indication have been good.^6,21,22

One final point to consider is the cost effectiveness of the implant. Recent evidence has shown that RTSA is associated with a higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, and increased hospital cost when compared with TSA.²³ This data may be biased as the patient selection for RTSA varies from that of TSA, but it is a point that must be considered. Other studies have shown that an RTSA is a cost-effective treatment option for treating patients with rotator cuff tear arthropathy, and is a more cost-effective option in treating rotator cuff tear arthropathy than hemiarthroplasty.^24,25 Similarly, RTSA offers a more cost-effective treatment option with better outcomes for patients with acute proximal humerus fractures when compared with open reduction internal fixation and hemiarthroplasty.²⁶ However, TSA is a more cost-effective treatment option than RTSA for patients with glenohumeral osteoarthritis.²⁷ With changing reimbursement in healthcare, surgeons must scrutinize not only anticipated outcomes with specific implants but the cost effectiveness of these implants as well. Further cost analysis studies are necessary to determine the ideal candidate for an RTSA.

LIMITATIONS

Despite its extensive review of the literature, this study had several limitations. While 2 independent authors searched for studies, it is possible that some studies were missed during the search process, introducing possible selection bias. No abstracts or unpublished works were included which could have introduced publication bias. Several studies did not report all variables the authors examined, and this could have skewed some of the results since the reporting of additional variables could have altered the data to show significant differences in some measured variables. As outcome measures for various pathologies were not compared, conclusions cannot be drawn on the best treatment option for various indications. As case reports were included, this could have lowered both the MCMS as well as the average in studies reporting outcomes. Furthermore, given the overall poor quality of the underlying data available for this study, the validity/generalizability of the results could be limited as the level of evidence of this systematic review is only as high as the studies it includes. There are subtle differences between rotator cuff arthropathy and pseudoparalysis, and some studies may have classified patients differently than others, causing differences in indications. Finally, as the primary goal of this study was to report on demographics, no evaluation of concomitant pathology at the time of surgery or rehabilitation protocols was performed.

CONCLUSION

The quantity, but not the quality of RTSA studies is increasing. Indications for RTSA varied by continent although most patients underwent RTSA for rotator cuff arthropathy. The majority of patients undergoing RTSA are female over the age of 60 years for a diagnosis of rotator cuff arthropathy with pseudoparalysis.

This paper will be judged for the Resident Writer’s Award.

ST. LOUIS – Many vascular surgery trainees felt unprepared to take the Registered Physician in Vascular Interpretation (RPVI) exam, according to a recent survey. However, trainees in a program without a structured noninvasive vascular laboratory (NIVL) curriculum felt particularly unprepared, said Daisy Chou, MD.

Kari Oakes/MDedge News

“There is wide variation in NIVL experience amongst vascular surgery training programs,” noted Dr. Chou, a vascular surgery fellow at the Ohio State University, Columbus. She presented survey results at the annual meeting of the Midwestern Vascular Surgical Society. The survey constructed by Dr. Chou and her colleagues went out to trainees in both 0+5 and 5+2 vascular surgery training programs in September, 2017, in 114 unique programs.

Eventually, trainees from just over half of the programs responded (N = 61 programs, 53.5%), said Dr. Chou. Using responses from individual trainees, the authors grouped programs into one of two categories: those whose trainees felt well prepared for the RPVI, and those whose trainees felt unprepared for the RPVI.

In addition to a yes/no question about preparedness, the survey also asked whether training programs had a structured curriculum; respondents were asked to identify specific NIVL-related training activities. The survey asked about individual didactic components, as well as whether the trainee spent individual time with an attending physician and hands-on time with vascular technologists. Respondents were asked about the amount of time, measured in half days per week, spent in the vascular laboratory.

Finally, the survey asked whether trainees took a pre-RPVI exam review course, and whether they passed the RPVI exam on their first attempt.

Overall, 34 of the programs with respondents (55.7%) had structured curricula; the same number included lectures. Twenty programs (32.8%) provided video content, and 29 (47.5%) used textbooks. Just 18 programs (29.5%) assigned articles.

One-on-one time spent with an attending physician and focused on NIVL techniques was reported for 32 programs (52.5%). More programs (n = 37; 60.7%) provided trainees hands-on experience with vascular technologists.

Most programs (n = 32; 52.5%) had trainees spending less than one half day per week in the vascular laboratory, according to survey respondents.

In terms of preparedness, respondents for over half of the programs did not respond to the question asking whether they felt prepared for the RPVI, presumably because they had not yet taken the exam. This, acknowledged Dr. Chou, was a significant limitation of the survey. There was a timing problem: Trainees were surveyed at the start of the 2017-2018 academic year, but the RPVI exam isn’t usually taken until the end of the final year of training, with review courses taken not long before that.

Of the 32 programs with trainees who reported taking the RPVI exam, 18 had trainees who felt unprepared, and 14 program had trainees who felt well prepared. About a quarter of programs (N = 15; 24.6%) had trainees who took a review course prior to taking the exam.

Dr. Chou and her colleagues then examined the survey responses another way, seeing what differentiated the programs whose trainees felt well prepared from those with trainees who felt unprepared.

Statistically, the clear standout was whether the program had a structured curriculum: The 14 programs with a structured curriculum all had students who reported feeling well prepared. Just one-third of the 18 programs with unprepared students had a structured curriculum, which was a significant difference (P = .0001).

Also, programs that assigned articles and those that gave formal lectures were more likely to have students who felt prepared to sit for the RPVI exam (P = .002 and .004, respectively). A higher number of programs that gave trainees hands-on time with vascular technologists had trainees who felt prepared, but the difference wasn’t quite statistically significant (P = .05).

Having taken a review course prior to the exam was associated with feeling well prepared (P = .03).

Dr. Chou and her colleagues performed a logistic regression analysis to arrive at the educational components associated with the highest odds for trainees feeling well prepared. Lectures and articles came out on top in this analysis (odds ratios for feeling well prepared, 15.88 and 15.97, respectively). Hands-on time with vascular technologists had an odds ratio of 5.12 for feeling prepared.

Taking a review course boosted preparedness as well, with an odds ratio of 11.85 for feeling well prepared for the RPVI exam. This created a bit of a conundrum for the investigators, said Dr. Chou: “All well prepared programs had a structured NIVL curriculum, but most of their trainees still took an RPVI review course, so it’s unclear if the structured curriculum or the review course is responsible for trainees feeling well prepared for the RPVI exam,” she said.

An important caveat to the analysis of survey results, said Dr. Chou, is that “It’s unknown how these results will translate into pass rates.

“Vascular surgery leadership should not leave NIVL education to review courses,” said Dr. Chou. The ultimate goal, she said, should be to achieve expertise in the service of providing better patient care. To this end, Dr. Chou and her coauthors recommend that a structured NIVL curriculum be incorporated into vascular surgery training, and that the program include time spent with vascular technologists, a formal lecture-based component, and structured reading, as is provided by a journal club.

Dr. Chou reported no conflicts of interest, and no external sources of funding.

koakes@mdedge.com

ST. LOUIS – Many vascular surgery trainees felt unprepared to take the Registered Physician in Vascular Interpretation (RPVI) exam, according to a recent survey. However, trainees in a program without a structured noninvasive vascular laboratory (NIVL) curriculum felt particularly unprepared, said Daisy Chou, MD.

Kari Oakes/MDedge News

“There is wide variation in NIVL experience amongst vascular surgery training programs,” noted Dr. Chou, a vascular surgery fellow at the Ohio State University, Columbus. She presented survey results at the annual meeting of the Midwestern Vascular Surgical Society. The survey constructed by Dr. Chou and her colleagues went out to trainees in both 0+5 and 5+2 vascular surgery training programs in September, 2017, in 114 unique programs.

Eventually, trainees from just over half of the programs responded (N = 61 programs, 53.5%), said Dr. Chou. Using responses from individual trainees, the authors grouped programs into one of two categories: those whose trainees felt well prepared for the RPVI, and those whose trainees felt unprepared for the RPVI.

In addition to a yes/no question about preparedness, the survey also asked whether training programs had a structured curriculum; respondents were asked to identify specific NIVL-related training activities. The survey asked about individual didactic components, as well as whether the trainee spent individual time with an attending physician and hands-on time with vascular technologists. Respondents were asked about the amount of time, measured in half days per week, spent in the vascular laboratory.

Finally, the survey asked whether trainees took a pre-RPVI exam review course, and whether they passed the RPVI exam on their first attempt.

Overall, 34 of the programs with respondents (55.7%) had structured curricula; the same number included lectures. Twenty programs (32.8%) provided video content, and 29 (47.5%) used textbooks. Just 18 programs (29.5%) assigned articles.

One-on-one time spent with an attending physician and focused on NIVL techniques was reported for 32 programs (52.5%). More programs (n = 37; 60.7%) provided trainees hands-on experience with vascular technologists.

Most programs (n = 32; 52.5%) had trainees spending less than one half day per week in the vascular laboratory, according to survey respondents.

In terms of preparedness, respondents for over half of the programs did not respond to the question asking whether they felt prepared for the RPVI, presumably because they had not yet taken the exam. This, acknowledged Dr. Chou, was a significant limitation of the survey. There was a timing problem: Trainees were surveyed at the start of the 2017-2018 academic year, but the RPVI exam isn’t usually taken until the end of the final year of training, with review courses taken not long before that.

Of the 32 programs with trainees who reported taking the RPVI exam, 18 had trainees who felt unprepared, and 14 program had trainees who felt well prepared. About a quarter of programs (N = 15; 24.6%) had trainees who took a review course prior to taking the exam.

Dr. Chou and her colleagues then examined the survey responses another way, seeing what differentiated the programs whose trainees felt well prepared from those with trainees who felt unprepared.

Statistically, the clear standout was whether the program had a structured curriculum: The 14 programs with a structured curriculum all had students who reported feeling well prepared. Just one-third of the 18 programs with unprepared students had a structured curriculum, which was a significant difference (P = .0001).

Also, programs that assigned articles and those that gave formal lectures were more likely to have students who felt prepared to sit for the RPVI exam (P = .002 and .004, respectively). A higher number of programs that gave trainees hands-on time with vascular technologists had trainees who felt prepared, but the difference wasn’t quite statistically significant (P = .05).

Having taken a review course prior to the exam was associated with feeling well prepared (P = .03).

Dr. Chou and her colleagues performed a logistic regression analysis to arrive at the educational components associated with the highest odds for trainees feeling well prepared. Lectures and articles came out on top in this analysis (odds ratios for feeling well prepared, 15.88 and 15.97, respectively). Hands-on time with vascular technologists had an odds ratio of 5.12 for feeling prepared.

Taking a review course boosted preparedness as well, with an odds ratio of 11.85 for feeling well prepared for the RPVI exam. This created a bit of a conundrum for the investigators, said Dr. Chou: “All well prepared programs had a structured NIVL curriculum, but most of their trainees still took an RPVI review course, so it’s unclear if the structured curriculum or the review course is responsible for trainees feeling well prepared for the RPVI exam,” she said.

An important caveat to the analysis of survey results, said Dr. Chou, is that “It’s unknown how these results will translate into pass rates.

“Vascular surgery leadership should not leave NIVL education to review courses,” said Dr. Chou. The ultimate goal, she said, should be to achieve expertise in the service of providing better patient care. To this end, Dr. Chou and her coauthors recommend that a structured NIVL curriculum be incorporated into vascular surgery training, and that the program include time spent with vascular technologists, a formal lecture-based component, and structured reading, as is provided by a journal club.

Dr. Chou reported no conflicts of interest, and no external sources of funding.

koakes@mdedge.com

ST. LOUIS – Many vascular surgery trainees felt unprepared to take the Registered Physician in Vascular Interpretation (RPVI) exam, according to a recent survey. However, trainees in a program without a structured noninvasive vascular laboratory (NIVL) curriculum felt particularly unprepared, said Daisy Chou, MD.

Kari Oakes/MDedge News

“There is wide variation in NIVL experience amongst vascular surgery training programs,” noted Dr. Chou, a vascular surgery fellow at the Ohio State University, Columbus. She presented survey results at the annual meeting of the Midwestern Vascular Surgical Society. The survey constructed by Dr. Chou and her colleagues went out to trainees in both 0+5 and 5+2 vascular surgery training programs in September, 2017, in 114 unique programs.

Eventually, trainees from just over half of the programs responded (N = 61 programs, 53.5%), said Dr. Chou. Using responses from individual trainees, the authors grouped programs into one of two categories: those whose trainees felt well prepared for the RPVI, and those whose trainees felt unprepared for the RPVI.

In addition to a yes/no question about preparedness, the survey also asked whether training programs had a structured curriculum; respondents were asked to identify specific NIVL-related training activities. The survey asked about individual didactic components, as well as whether the trainee spent individual time with an attending physician and hands-on time with vascular technologists. Respondents were asked about the amount of time, measured in half days per week, spent in the vascular laboratory.

Finally, the survey asked whether trainees took a pre-RPVI exam review course, and whether they passed the RPVI exam on their first attempt.

Overall, 34 of the programs with respondents (55.7%) had structured curricula; the same number included lectures. Twenty programs (32.8%) provided video content, and 29 (47.5%) used textbooks. Just 18 programs (29.5%) assigned articles.

One-on-one time spent with an attending physician and focused on NIVL techniques was reported for 32 programs (52.5%). More programs (n = 37; 60.7%) provided trainees hands-on experience with vascular technologists.

Most programs (n = 32; 52.5%) had trainees spending less than one half day per week in the vascular laboratory, according to survey respondents.

In terms of preparedness, respondents for over half of the programs did not respond to the question asking whether they felt prepared for the RPVI, presumably because they had not yet taken the exam. This, acknowledged Dr. Chou, was a significant limitation of the survey. There was a timing problem: Trainees were surveyed at the start of the 2017-2018 academic year, but the RPVI exam isn’t usually taken until the end of the final year of training, with review courses taken not long before that.

Of the 32 programs with trainees who reported taking the RPVI exam, 18 had trainees who felt unprepared, and 14 program had trainees who felt well prepared. About a quarter of programs (N = 15; 24.6%) had trainees who took a review course prior to taking the exam.

Dr. Chou and her colleagues then examined the survey responses another way, seeing what differentiated the programs whose trainees felt well prepared from those with trainees who felt unprepared.

Statistically, the clear standout was whether the program had a structured curriculum: The 14 programs with a structured curriculum all had students who reported feeling well prepared. Just one-third of the 18 programs with unprepared students had a structured curriculum, which was a significant difference (P = .0001).

Also, programs that assigned articles and those that gave formal lectures were more likely to have students who felt prepared to sit for the RPVI exam (P = .002 and .004, respectively). A higher number of programs that gave trainees hands-on time with vascular technologists had trainees who felt prepared, but the difference wasn’t quite statistically significant (P = .05).

Having taken a review course prior to the exam was associated with feeling well prepared (P = .03).

Dr. Chou and her colleagues performed a logistic regression analysis to arrive at the educational components associated with the highest odds for trainees feeling well prepared. Lectures and articles came out on top in this analysis (odds ratios for feeling well prepared, 15.88 and 15.97, respectively). Hands-on time with vascular technologists had an odds ratio of 5.12 for feeling prepared.

Taking a review course boosted preparedness as well, with an odds ratio of 11.85 for feeling well prepared for the RPVI exam. This created a bit of a conundrum for the investigators, said Dr. Chou: “All well prepared programs had a structured NIVL curriculum, but most of their trainees still took an RPVI review course, so it’s unclear if the structured curriculum or the review course is responsible for trainees feeling well prepared for the RPVI exam,” she said.

An important caveat to the analysis of survey results, said Dr. Chou, is that “It’s unknown how these results will translate into pass rates.

“Vascular surgery leadership should not leave NIVL education to review courses,” said Dr. Chou. The ultimate goal, she said, should be to achieve expertise in the service of providing better patient care. To this end, Dr. Chou and her coauthors recommend that a structured NIVL curriculum be incorporated into vascular surgery training, and that the program include time spent with vascular technologists, a formal lecture-based component, and structured reading, as is provided by a journal club.

Dr. Chou reported no conflicts of interest, and no external sources of funding.