Author:  June Kennedy

BACKGROUND

I work full-time at Duke Sports Medicine Physical Therapy with a practice focus on the degenerative shoulder. I rehabilitate a high volume of patients who have had RTSA, and have observed anecdotally differences in patient outcomes and complications for varied pre-operative indications. Additionally, I serve as a resource locally for Duke Health Systems, and also as an international speaker on the topic of rehabilitation after RTSA. A systematic review of the literature to analyze clinical and patient reported outcomes following RTSA stratified by pre-operative diagnosis will be impactful to surgeons, therapists and patients for establishing expectations for recovery. Publishing and presenting this information will fulfill a professional goal that I have to not only understand this question for my own practice, but also to share the information for the growth and development of others in my profession.

STATEMENT OF NEED

Reverse total shoulder arthroplasty (RTSA) was approved for use in the United States in 2004 for the treatment of rotator cuff tear arthropathy. The design of the prosthetic implant employs fixed fulcrum mechanics that medialize the glenohumeral center of rotation such that the deltoid functions as both an elevator and compressor to the joint thereby compensating for rotator cuff deficiency.(1) The utility of the prosthesis has expanded to include management of primary glenohumeral osteoarthritis with excessive glenoid erosion with an intact rotator cuff, massive irreparable rotator cuff tear without arthritis, rheumatoid arthritis, proximal humeral fracture, revision of anatomic total shoulder arthroplasty, and other complicated shoulder conditions such as tumors.(2) Clinical and patient reported outcomes may vary following RTSA dependent on the pre-operative diagnosis due to differences in the status of the rotator cuff and pre-operative functional mobility. For example, patients having RTSA for primary osteoarthritis with an intact rotator cuff may have greater internal and external rotation range of motion and strength as compared to those who have the procedure for management of cuff tear arthropathy or a massive irreparable rotator cuff tear. A second example is a comparison of outcome following RTSA for fracture in a patient with high level pre-operative function compared to a patient who has the procedure for management of chronic rheumatoid arthritis with very limited functionality prior to surgery. The fracture patient may appreciate a quicker return of deltoid strength and overall shoulder function due to the higher level pre-operative status as compared to the patient with rheumatoid arthritis.
One research project reports on variable clinical and patient-reported outcomes following RTSA based on pre-operative diagnosis, however the data is twelve years old and the utility of RTSA has increased greatly since this publication.(3) A more recent report investigates the outcome of RTSA stratified by pre-operative diagnoses, however this paper reflects outcomes for one practice which may not be generalizable.(4) Additionally, the author assesses whether or not each diagnosis reached the minimal clinically important difference for variables in lieu of publishing the delta value of pre-operative to post-operative change for reported outcomes. Knowledge about outcomes for RTSA for variable diagnoses can assist rehabilitation specialists in setting appropriate patient goals, and also aid in helping patients develop realistic expectations for recovery. Expectation is closely linked to patient satisfaction,(5,6) therefore establishing differences in outcomes following RTSA for different pre-operative diagnoses is impactful.

METHOD

Preferred Reporting of Information for Systematic Reviews and Meta-analysis (PRISMA) methodology was employed to assess clinical and patient reported outcomes of RTSA for the following diagnoses: 1. Cuff tear arthropathy, 2. Primary glenohumeral osteoarthritis with an intact rotator cuff; 3. Massive irreparable rotator cuff tear without arthritis; 4. Rheumatoid arthritis; 5. Proximal humeral fracture; and 6. Revision of anatomic total shoulder arthroplasty. Additional aims of this project were to report on 1. the quality of research, and 2. the rate of complications as well as the cause for the complications following RTSA for the papers included in the review.

PRODUCT

The following manuscript was written with fellow committee members Garrett Bullock, PT, DPT and Chris Klifto, MD:

manuscript 4.16.20_B

EVALUATION

On-going evaluation of my progress on this systematic review was two-fold:
1.  Referring to the proposed timeline to ensure that our committee was staying focused and on track
2.  Consultation with Garrett Bullock, who was my committee member with extensive experience in systematic review process. He coached me in the method of risk of bias assessment, data extraction, data synthesis and analysis and provided extensive editing to the manuscript. Garrett also provided feedback on what exactly needed referencing.

Ultimately we will submit this manuscript for publication in JOSPT – hopefully over the next couple of months after we finish honing the text and determine if we are able to conduct a meta-analysis. This will provide a terrific evaluation of our product as it will be peer-reviewed for this publication. Also, we will be applying to present this at Combined Sections Meeting 2021 as well as at the 2020 annual conference of the American Society of Shoulder and Elbow Therapists. This will provide peer feedback at the highest level.

SELF-REFLECTION

I have learned a tremendous amount in the process of leading this systematic review. Not only have I learned about the topic – outcomes for reverse shoulder arthroplasty according to the pre-operative diagnosis, but I have learned about the rigors of conducting a systematic review. The process of scoring risk of bias was new to me, as was synthesizing data in an excel spreadsheet, and then analyzing it to inform the clinical relevance. The entire process has enhanced my ability to read and critique and carefully apply research findings to my practice.

ACKNOWLEDGEMENTS

There is no way I could have completed this project without the constant support of my husband, Mark Kennedy. He absorbed laundry, cooking, and was exceptionally patient with my lack of time due to working full-time while in school. Mark also shared expertise in navigating Microsoft Excel for data management/synthesis and was a great resource for this important phase of the project.

Garrett Bullock, PT, DPT is nothing short of a genius. And an extremely humorous and humble one. Garrett was always ready to answer my many questions, conducted his tasks of risk of bias assessment and data extraction very promptly and effectively, and gave this project 110% in time and energy. Garrett’s edits to the manuscript greatly enhanced the quality of the writing and analysis of results.

Chris Klifto, MD, is extremely busy as an Orthopedic surgeon, father, and husband. He gave generously of his time to also work on risk of bias assessment and data extraction for a portion of the data, and was positive and supportive every step of the way! I am glad to partner with him in this project, as well as many patients’ care.

Mike Gross has been a faithful advisor to me once again! I have appreciated the positive feedback along the way and support to my professional development. Mike encouraged me to enter this tDPT program and it has been very formative for my learning and growth at many levels. Thank you Mike!

Last but definitely not least, I have much gratitude toward Bob Bruzga, PT , ATC, OCS, SCS and Dan Dore, PT, DPT who are my manager and the Director of Duke Physical and Occupational Therapy, respectively, for their support to me to constantly grow and learn.  The have endorsed my participation in this program and I am very grateful to them.

REFERENCES

1. Kazley JM, Cole KP, Desai KJ, Zonshayn S, Morse AS, Banerjee S. Prostheses for reverse total shoulder arthroplasty. Expert Rev Med Devices. 2019;16(2):107-118. doi:10.1080/17434440.2019.1568237
2. Rugg CM, Coughlan MJ, Lansdown DA. Reverse total shoulder arthroplasty: biomechanics and indications. Curr Rev Musculoskelet Med. 2019;12(4):542-553. doi:10.1007/s12178-019-09586-y
3. Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476-1485. doi:10.2106/JBJS.F.00666
4. Lindbloom BJ, Christmas KN, Downes K, et al. Is there a relationship between preoperative diagnosis and clinical outcomes in reverse shoulder arthroplasty? An experience in 699 shoulders. J Shoulder Elbow Surg. 2019;28(6S):S110-S117. doi:10.1016/j.jse.2019.04.007
5. Rauck RC, Swarup I, Chang B, et al. Effect of preoperative patient expectations on outcomes after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2018;27(11):e323-e329. doi:10.1016/j.jse.2018.05.026
6. Rauck RC, Swarup I, Chang B, et al. Preoperative patient expectations of elective reverse shoulder arthroplasty. J Shoulder Elbow Surg. March 2019. doi:10.1016/j.jse.2018.12.008

Picture reference: https://en.wikipedia.org/wiki/Reverse_shoulder_replacement