Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
NIHR Oxford Biomedical Research Centre, Oxford, UK.
BMJ. 2024 Apr 30;385:e077939. doi: 10.1136/bmj-2023-077939.
To answer a national research priority by comparing the risk-benefit and costs associated with reverse total shoulder replacement (RTSR) and anatomical total shoulder replacement (TSR) in patients having elective primary shoulder replacement for osteoarthritis.
Population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England.
Public hospitals and publicly funded procedures at private hospitals in England, 2012-20.
Adults aged 60 years or older who underwent RTSR or TSR for osteoarthritis with intact rotator cuff tendons. Patients were identified from the National Joint Registry and linked to NHS Hospital Episode Statistics and civil registration mortality data. Propensity score matching and inverse probability of treatment weighting were used to balance the study groups.
The main outcome measure was revision surgery. Secondary outcome measures included serious adverse events within 90 days, reoperations within 12 months, prolonged hospital stay (more than three nights), change in Oxford Shoulder Score (preoperative to six month postoperative), and lifetime costs to the healthcare service.
The propensity score matched population comprised 7124 RTSR or TSR procedures (126 were revised), and the inverse probability of treatment weighted population comprised 12 968 procedures (294 were revised) with a maximum follow-up of 8.75 years. RTSR had a reduced hazard ratio of revision in the first three years (hazard ratio local minimum 0.33, 95% confidence interval 0.18 to 0.59) with no clinically important difference in revision-free restricted mean survival time, and a reduced relative risk of reoperations at 12 months (odds ratio 0.45, 95% confidence interval 0.25 to 0.83) with an absolute risk difference of -0.51% (95% confidence interval -0.89 to -0.13). Serious adverse events and prolonged hospital stay risks, change in Oxford Shoulder Score, and modelled mean lifetime costs were similar. Outcomes remained consistent after weighting.
This study's findings provide reassurance that RTSR is an acceptable alternative to TSR for patients aged 60 years or older with osteoarthritis and intact rotator cuff tendons. Despite a significant difference in the risk profiles of revision surgery over time, no statistically significant and clinically important differences between RTSR and TSR were found in terms of long term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.
通过比较与反向全肩关节置换术（RTSR）和解剖全肩关节置换术（TSR）相关的风险-效益和成本，为国家研究重点提供答案，适用于因骨关节炎行择期初次肩关节置换的患者。
基于人群的队列研究，使用来自英格兰国家关节登记处和医院入院统计数据的数据。
英格兰公立医院和私人医院的公共资助程序。
年龄在 60 岁或以上、因骨关节炎伴完整肩袖肌腱而行 RTSR 或 TSR 的成年人。从国家关节登记处识别患者，并与国民保健制度医院入院统计数据和民事登记死亡率数据相关联。采用倾向评分匹配和治疗逆概率加权来平衡研究组。
主要观察指标是翻修手术。次要观察指标包括术后 90 天内的严重不良事件、12 个月内的再次手术、住院时间延长（超过三晚）、牛津肩部评分（术前至术后 6 个月）的变化，以及终生医疗服务成本。
倾向评分匹配人群包括 7124 例 RTSR 或 TSR 手术（126 例被翻修），治疗逆概率加权人群包括 12968 例手术（294 例被翻修），随访时间最长为 8.75 年。在头三年，RTSR 降低了翻修的风险比（局部最小危险比 0.33，95%置信区间 0.18 至 0.59），但在无翻修的限制性平均生存时间方面没有临床意义上的差异，并且在 12 个月时降低了再次手术的相对风险（比值比 0.45，95%置信区间 0.25 至 0.83），绝对风险差异为-0.51%（95%置信区间-0.89 至-0.13）。严重不良事件和住院时间延长的风险、牛津肩部评分的变化以及模型化的平均终生成本相似。加权后结果仍然一致。
本研究结果为 60 岁及以上因骨关节炎伴完整肩袖肌腱而行 RTSR 的患者提供了信心，RTSR 是 TSR 的可接受替代方案。尽管随着时间的推移，翻修手术的风险特征存在显著差异，但在长期翻修手术、严重不良事件、再次手术、住院时间延长或终生医疗保健成本方面，RTSR 和 TSR 之间没有统计学意义上的显著差异。
