Why has reverse total shoulder arthroplasty become the procedure of choice for primary shoulder arthroplasty?

For those orthopedic surgeons performing arthroplasty, it has become quite evident that in a relatively short period of time, reverse total shoulder arthroplasty (RTSA) has become the most commonly performed shoulder arthroplasty procedure.362021 hip and knee implant review.Orthop Netw News. 2021; 32 (Available at:): 8-9https://meeting.aahks.org/wp-content/uploads/ONN_2020_Hip_Knee.pdfGoogle Scholar This is particularly interesting considering that 25 years ago RTSA was not performed in the United States at all and has only been approved by the Food and Drug Administration (FDA) for use since 2003.9Food and Drug AdministrationDelta shoulder. DePuy 510 (k) K021478, summary.https://www.accessdata.fda.gov/cdrh_docs/pdf2/k021478.pdfDate: 2003Google Scholar Nonetheless, today RTSA accounts for the vast majority of all shoulder arthroplasties performed in the United States.362021 hip and knee implant review.Orthop Netw News. 2021; 32 (Available at:): 8-9https://meeting.aahks.org/wp-content/uploads/ONN_2020_Hip_Knee.pdfGoogle Scholar Is this rapid rise to prominence a product of RTSA being a technologically advanced and advantageous procedure or does it represent an overzealous utilization by orthopedic surgeons or is it a combination of both factors? Given the rapid expansion of the use of RTSA, it is worthwhile to consider and understand the reasons for these developments. The concept of the modern RTSA was first developed by Dr. Paul Grammont in the 1980s.12Grammant P.M. Baulot E. Delta shoulder prosthesis for rotator cuff rupture.Orthopedics. 1993; 16: 65-68Crossref Scopus (520) Google Scholar Before that time, efforts by many surgeons to develop fixed fulcrum design shoulder arthroplasty were consistently unsuccessful and the effort was largely abandoned.15Jazayeri R. Friedman A. The evolution of shoulder arthroplasty.in: Zuckerman J.D. Shoulder arthroplasty: principles and practice. Wolters Kluwer, Philadelphia2021Google Scholar Grammont approached the problem differently than his predecessors. The basic design concept of a medialized center of rotation on the glenoid combined with distalization of the humerus progressed through different iterations in France to ultimately become the Delta III RTSA.2Boileau P. Watkinson D. Hatzidakis A.M. Balg F. Grammont reverse shoulder prosthesis: design, rationale and biomechanics.J Shoulder Elbow Surg. 2005; 14: 147S-161Shttps://doi.org/10.1016/j.jse.2004.10.006Abstract Full Text Full Text PDF PubMed Scopus (884) Google Scholar The clinical results in Europe ultimately led to approval by the FDA in 2003 for use in the United States. At that time, the specific indication for use of the Delta III was rotator cuff arthropathy.9Food and Drug AdministrationDelta shoulder. DePuy 510 (k) K021478, summary.https://www.accessdata.fda.gov/cdrh_docs/pdf2/k021478.pdfDate: 2003Google Scholar At the same time, another RTSA design was being developed and investigated in the United States by Frankle et al.10Frankle M. Siegal S. Pupello D. Saleem A. Mighell M. Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year-follow-up study of sixty patients.J Bone Joint Surg Am. 2005; 87: 1697-1705https://doi.org/10.2106/JBJS.D.02813Crossref PubMed Scopus (654) Google Scholar This implant system eventually gained FDA approval for use in “rotator cuff tear arthropathy” and “failed joint replacement with a deficient rotator cuff.” A multitude of RTSA designs followed and were approved for use by the FDA under the 510(k) predicate device process.20Kuhn J. Weber S. St. Pierre P. Brockmeier S. Garrigues G. Navarro R. et al.Off label use of reverse total shoulder arthroplasty: the AAOS shoulder and elbow registry.Sem Arthroplasty. 2023; 33: 261-269https://doi.org/10.1053/j.sart.2022.11.003Abstract Full Text Full Text PDF Scopus (1) Google Scholar Over the past 20 years, FDA approvals have generally specified indications for rotator cuff arthropathy and a failed prosthesis. More recently, additional indications have been approved for specific implants based on the requests of the implant company submitting the application. These indications include osteonecrosis of the humeral head, rheumatoid arthritis, osteoarthritis, traumatic arthritis, and proximal humeral nonunions.20Kuhn J. Weber S. St. Pierre P. Brockmeier S. Garrigues G. Navarro R. et al.Off label use of reverse total shoulder arthroplasty: the AAOS shoulder and elbow registry.Sem Arthroplasty. 2023; 33: 261-269https://doi.org/10.1053/j.sart.2022.11.003Abstract Full Text Full Text PDF Scopus (1) Google Scholar The evolution of the use of RTSA is an interesting one that deserves our attention. In 2007, Rockwood, “as one of the senior shoulder surgeons in this country and a founding member of the American Shoulder and Elbow Surgeons,” wrote an editorial for the Journal of Bone and Joint Surgery entitled “The reverse total shoulder prosthesis: the new kid on the block.”29Rockwood C. The reverse total shoulder prosthesis: the new kid on the block.J Bone Joint Surg Am. 2007; 89: 233-235https://doi.org/10.2106/JBJS.F.01394Crossref PubMed Scopus (0) Google Scholar This editorial preceded the article by Levy et al23Levy J. Frankle M. Mighell M. Pupello B. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture.J Bone Joint Surg Am. 2007; 89: 292-300https://doi.org/10.2106/JBJS.E.01310Crossref PubMed Scopus (286) Google Scholar that described the use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty previously performed for proximal humeral fracture.10Frankle M. Siegal S. Pupello D. Saleem A. Mighell M. Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year-follow-up study of sixty patients.J Bone Joint Surg Am. 2005; 87: 1697-1705https://doi.org/10.2106/JBJS.D.02813Crossref PubMed Scopus (654) Google Scholar Rockwood expressed his concerns about the reverse shoulder prosthesis. His concern was based on the significant complication rates reported by multiple authors who were instrumental in developing the procedure including Walch et al,33Walch G. Wall B. Mottier F. Complications and revision of the reverse prosthesis, a multicenter study of 457 cases.in: Walch G. Boileau P. Mole` D. Favard L. Levigne C. Sirveaux F. Reverse shoulder arthroplasty; clinical results, complications, revision. Sauramps Medical, Montpellier, France2006: 335-352https://doi.org/10.2106/JBJS.16.00935Google Scholar Boileau et al,3Boileau P. Watkinson D. Hatzidakis A.M. Hovorka I. The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty.J Shoulder Elbow Surg. 2006; 15: 527-540https://doi.org/10.1016/j.jse.2006.01.003Abstract Full Text Full Text PDF PubMed Scopus (817) Google Scholar and Gerber et al.34Werner C.M. Steinman P.A. Gilbart M. Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.J Bone Joint Surg Am. 2005; 87: 1476-1486https://doi.org/10.2106/JBJS.D.02342Crossref PubMed Scopus (844) Google Scholar Complications in these different reports ranged from 13% to 50%. They tended to be lower when primary arthroplasty was performed and higher when performed as a revision procedure. Levy et al,23Levy J. Frankle M. Mighell M. Pupello B. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture.J Bone Joint Surg Am. 2007; 89: 292-300https://doi.org/10.2106/JBJS.E.01310Crossref PubMed Scopus (286) Google Scholar although reporting satisfactory overall results, reported a complication rate of 28%. These results significantly tempered the initial enthusiasm for this procedure. Walch et al33Walch G. Wall B. Mottier F. Complications and revision of the reverse prosthesis, a multicenter study of 457 cases.in: Walch G. Boileau P. Mole` D. Favard L. Levigne C. Sirveaux F. Reverse shoulder arthroplasty; clinical results, complications, revision. Sauramps Medical, Montpellier, France2006: 335-352https://doi.org/10.2106/JBJS.16.00935Google Scholar stated that “on the basis of the current design and results the reverse prosthesis should be considered a salvage procedure: its use should be limited to elderly patients, arguably those over the age of 70 years with poor function and severe pain related to cuff deficiency. A reverse prosthesis should not be offered to a young individual who desires to have a normal shoulder and will demand more of the prosthesis than it is designed to do.” Gerber et al34Werner C.M. Steinman P.A. Gilbart M. Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.J Bone Joint Surg Am. 2005; 87: 1476-1486https://doi.org/10.2106/JBJS.D.02342Crossref PubMed Scopus (844) Google Scholar shared their concern and stated that “because of the high complication rate and the fact that there may be long-term complications that are not yet known, arthroplasty with this implant should be reserved for a salvage procedure for situations in which an acceptable clinical outcome cannot be expected with another treatment modality.” Both of these clinical series reported on the results of the Delta III implant. Although Rockwood29Rockwood C. The reverse total shoulder prosthesis: the new kid on the block.J Bone Joint Surg Am. 2007; 89: 233-235https://doi.org/10.2106/JBJS.F.01394Crossref PubMed Scopus (0) Google Scholar felt that “the reverse shoulder prosthesis can yield satisfactory and even spectacular results when used by an experienced shoulder surgeon,” he also felt strongly that it was not for the “inexperienced surgeon.” He suggested 5 criteria that should be used by an “inexperienced shoulder surgeon” in order to even consider using this implant. The situation has clearly changed since 2007. Although the initial reports by Boileau et al, Walch et al, Gerber et al, Frankle et al, and others may have reported significant complications and urged caution with use of the RTSA, these same individuals have become strong proponents of the procedure for a wider range of indications rather than as a “salvage procedure.” The initial rates of complications that included infection, scapular notching, humeral fracture, glenoid loosening, humeral loosening, humeral disassembly, glenoid disassembly, hematoma, neuropraxia, scapular spine fracture, and postoperative stiffness are no longer reported even remotely close to the incidence in the initial reports. Improvements in surgical technique, implant design, and expanding experience with the procedure have resulted in the RTSA becoming a very successful and reliable treatment option.7Collin P. Herve A. Walch G. Boileau P. Muniandy M. Chelli M. Mid-term results of reverse shoulder arthroplasty for glenohumeral osteoarthritis with posterior glenoid efficiency and humeral subluxation.J Shoulder Elbow Surg. 2019; 28: 2023-2030https://doi.org/10.1016/j.jse.2019.03.002Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar,8Cuff D.J. Pupello D.R. Sanoni B.G. Clark R.E. Frankle M.A. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency: a concise follow-up, at a minimum of 10 years, of previous reports.J Bone Joint Surg Am. 2017; 99: 1895-1899https://doi.org/10.2106/JBJS.17.00175Crossref PubMed Scopus (102) Google Scholar,16Kany J.R. Dubiel M.J. Cofiel R.H. Steinmann S.P. Elhassan B.T. Morrey M.E. et al.Primary reverse shoulder arthroplasty using contemporary implants is associated with very low reoperation rates.J Shoulder Elbow Surg. 2019; 28: S175-S180https://doi.org/10.1016/j.jse.2019.01.026Abstract Full Text Full Text PDF Scopus (46) Google Scholar,21Larose G. Fisher N.D. Gambhir N. Alben M.G. Zuckerman J.D. Virk M.S. et al.Inlay versus onlay humeral design for reverse shoulder arthroplasty: a systemic review and meta-analysis.J Shoulder Elbow Surg. 2022; 31: 2410-2420https://doi.org/10.1016/j.jse.2022.05.002Abstract Full Text Full Text PDF Scopus (6) Google Scholar,22Levin J.M. Bokshan S. Roche C.P. Zuckerman J.D. Wright T. Flurin P.H. et al.Reverse shoulder arthroplasty with and without baseplate wedge augmentation in the setting of glenoid deformity and rotator cuff deficiency—a multicenter investigation.J Shoulder Elbow Surg. 2022; 31: 2488-2496https://doi.org/10.1016/j.jse.2022.04.025Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,32Virk M. Yip M. Liuzza L. Abdelshahed M. Paoli A. Grey S. et al.Clinical and radiographic outcomes with a posteriorly augmented glenoid for Walch B2, B3, and C glenoid in reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2020; 29: e196-204https://doi.org/10.1016/j.jse.2019.09.031Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Even the incidence of scapular notching, which was a significant concern with the use of the Grammont design implants, has been essentially solved with new implant designs and changes in surgical technique. As we progressed through the “learning curve” related to technique, implant design, and recognition of the role of Cutibacterium acnes as a causative agent in postoperative infection, the outcomes after RTSA have become comparable to anatomic total shoulder arthroplasty (ATSA) when performed for primary shoulder arthroplasty.26Neel G.B. Eichinger J.K. Roche C. Flurin P.H. Wright T.W. Zuckerman J.D. et al.Prospective observational study of anatomic and reverse total shoulder arthroplasty utilizing a single implant system with long-term follow-up.Semin Arthroplasty. 2023; 33: 8-14https://doi.org/10.1053/j.sart.2022.07.014Abstract Full Text Full Text PDF Scopus (1) Google Scholar,30Schoch B.S. King J.J. Zuckerman J. Wright T.W. Roche C. Flurin P.-H. Anatomic versus reverse shoulder arthroplasty; a mid-term follow-up comparison.Shoulder Elbow. 2021; 13: 518-526https://doi.org/10.1177/1758573220921150Crossref PubMed Scopus (18) Google Scholar,31Schoch B.S. King J.J. Fan W. Flurin P.H. Wright T.W. Zuckerman J.D. et al.Characteristics of anatomic and reverse total shoulder arthroplasty patients who achieve ceiling scores with 3 common patient-reported outcome measures.J Shoulder Elbow Surg. 2022; 31: 1647-1657https://doi.org/10.1016/j.jse.2022.01.142Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar,35Wright M.A. Keener J.D. Chamberlain A.M. Comparison of clinical outcomes after anatomic total shoulder arthroplasty and reverse shoulder arthroplasty in patients 70 years and older with glenohumeral osteoarthritis and an intact rotator cuff.J Am Acad Orthop Surg. 2020; 28: c222-c229https://doi.org/10.5435/JAAOS-D-19-00166Crossref PubMed Scopus (76) Google Scholar In these comparisons, the literature is mixed on which one is “better” but the consistent message is that the outcomes of both are generally excellent.11Friedman R. Schoch B. Eichinger J.K. Neel G. Boettcher M.L. Flurin P.H. et al.Comparison of reverse and anatomic total shoulder arthroplasty in patients with an intact rotator cuff and no previous surgery.J Am Acad Orthop Surg. 2022; 30: 941-948https://doi.org/10.5435/JAAOS-D-22-00014Crossref Scopus (2) Google Scholar,18Kirsh J. Puzzitiello R. Swanson D. Le K. Hart P.A. Churchill R. et al.Outcomes after anatomic and reverse shoulder arthroplasty for the treatment of glenohuemral osteoarthritis: a propensity score-matched analysis.J Bone Joint Surg Am. 2022; 104: 1362-1369https://doi.org/10.2106/JBJS.21.00982Crossref Scopus (9) Google Scholar,25Nazzal E. Reddy R.P. Como M. Rai A. Greiner J.J. Fox M.A. et al.Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.J Shoulder Elbow Surg. 2023; 32: S60-S68https://doi.org/10.1016/j.jse.2023.02.005Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In addition, the RTSA is used for a much wider range of glenohumeral conditions when compared with ATSA. The situation is now much different than at the time of Rockwood’s editorial and the initial reports of outcomes after RTSA. The reason for the “explosion” in the use of RTSA is clearly a product of the expanded indications for the procedure. Even though the FDA has only approved its use for a limited number of clinical conditions, its use for a wide range of glenohumeral degenerative disorders is a result of each surgeon’s assessment of the clinical and radiographic factors for each patient. When the surgeon assesses this multifactorial equation to determine treatment, each one may weigh each factor differently to determine whether to proceed with RTSA or ATSA. This is important to understand because it makes the decision of ATSA vs. RTSA very surgeon dependent. In my own practice, of the most recent 200 primary shoulder arthroplasties, RTSA has accounted for 78% and ATSA 22%. Over the past 2 years, I have moderated multiple panel discussions on the specific topic of: ATSA vs. RTSA: How Do You Decide? In each of these discussions, I asked the panel to consider a patient with an underlying diagnosis of glenohumeral arthritis with an intact rotator cuff and no previous surgery or injury. I then asked the faculty to consider other factors that may impact their decision-making including age, gender, degree, and type of glenoid deformity and degree of posterior humeral head subluxation. I would also then replace osteoarthritis with a different underlying diagnosis to determine how it impacted their decision-making. As expected, the responses have been variable. Some consider age an absolute indication for RTSA, and opinions range from over 75, over 70, and even over 65. Gender is generally not cited as a major factor although RTSA seemed more likely to be selected for women. The degree of posterior glenoid wear with retroversion of more than 15°-20° is also cited as another indication for RTSA. Posterior humeral head subluxation greater than 90% was also cited almost unanimously as an indication. However, some noted that humeral head subluxation greater than 80% was considered an indication. When adding an underlying diagnosis of Parkinson’s disease, RTSA was the preferred procedure. When rheumatoid arthritis was added, once again, RTSA most often became the procedure of choice. In other clinical situations including lower extremity paraplegia, RTSA was commonly preferred because of the stresses on the weight-bearing upper extremities and the opportunity to resume the use of the upper extremities more quickly and with less risk than after ATSA. When considering other clinical diagnoses that impact the integrity and morphology of the soft tissues and bony anatomy including massive rotator cuff tears without arthritis, acute comminuted proximal humeral fractures, post-traumatic arthritis, previous open anterior shoulder repairs including previous Laterjet procedures, and tumors, RTSA was consistently cited as the preferred procedure. Although this has been clearly been the trend, it is also important that the literature reports that ATSA, especially when augmented glenoid components are used, results in excellent outcomes in the context of B2 and B3 glenoid deformity6Chin P. Hachadorian M.E. Pulido P.A. Munro M.L. Gokhan M. Hoenecke Jr., H.R. Outcomes of anatomic shoulder arthroplasty in primary osteoarthritis in type B glenoids.J Shoulder Elbow Surg. 2015; 24: 1888-1893https://doi.org/10.1016/j.jse.2015.05.052Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,13Harold R.E. Sweeney P.T. Torchia M. Chamberlain A. Keener J.D. Total shoulder arthroplasty in patients with a B2 glenoid addressed with corrective reaming: mean 8-year follow-up.J Shoulder Elbow Surg. 2023; 32: S8-S16https://doi.org/10.1016/j.jse.2022.12.019Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,14Hinse S. Pastor T. Hasler A. Ernstbrunner L. Wieser K. Gerber C. Mid-to long-term clinical and radiological results of anatomic total shoulder arthroplasty in patients with B2 glenoids.JSES Int. 2023; 7: 464-471https://doi.org/10.1016/j.jseint.2023.01.006Abstract Full Text Full Text PDF Scopus (0) Google Scholar,19Kohan E.M. Hendy B.A. Kowal L.L. Kirsch J. Pietro G. Williams G. et al.Mid-to long term outcomes of augmented and nonaugmented anatomic shoulder arthroplasty in Walch B3 glenoids.J Shoulder Elbow Surg. 2022; 31: S103-S109https://doi.org/10.1016/j.jse.2021.12.016Abstract Full Text Full Text PDF Scopus (4) Google Scholar,24Matsen F. Whitson A. Somerson J. Hsu J. Anatomic total shoulder arthroplasty with all-polyethylene glenoid component for primary osteoarthritis with glenoid deficiencies.JB JS Open Access. 2020; 5e20.00002https://doi.org/10.2016/JBJS.OA.20.00002Crossref Google Scholar,27Polisetty T.S. Swanson D.P. Hart P.A.J. Cannon D.J. Glass E.A. Jawa A. et al.Anatomic and reverse shoulder arthroplasty for management of type B2 and B3 glenoids: a matched-cohort analysis.J Shoulder Elbow Surg. 2023; 32: 1629-1637https://doi.org/10.1016/j.jse.2023.02.125Abstract Full Text Full Text PDF Scopus (0) Google Scholar,32Virk M. Yip M. Liuzza L. Abdelshahed M. Paoli A. Grey S. et al.Clinical and radiographic outcomes with a posteriorly augmented glenoid for Walch B2, B3, and C glenoid in reverse total shoulder arthroplasty.J Shoulder Elbow Surg. 2020; 29: e196-204https://doi.org/10.1016/j.jse.2019.09.031Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar and C glenoid deformity. Similarly, satisfactory results after ATSA have been reported in patients with inflammatory arthritis.4Centers for Medicare & Medicaid Serviceshttps://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/wage-indexGoogle Scholar Nonetheless, these reports and others have not changed the current practice trends that are evident. Recognizing that RTSA is the preferred procedure when considering these clinical and anatomic factors, it is easy to understand how it has become far more commonly performed than ATSA. If we add the 2 “approved” indications—rotator cuff arthropathy and revision of previous joint replacement with rotator cuff deficiency—the percentage of RTSA performed only increases. There is another factor that also adds to the preference to RTSA; it is considered an easier procedure to perform than ATSA with less short-term concerns for instability and longer-term concerns for rotator cuff failure. I also would add that the relatively shorter time to perform the procedure compared with ATSA may also be a factor in procedure selection. It is clear that both the “indications” for RTSA and the “reasons” why it is preferred by orthopedic surgeons explain why RTSA now comprises upward of 80% of all shoulder arthroplasties performed. In this context, an important question to ask is: “what is the indication for ATSA?” In these panel discussions, it has also become evident that for most surgeons, the indications for ATSA have become much more limited and specific: essentially younger age patients (under age 70? and under age 65?) with noninflammatory glenohumeral arthritis and an intact rotator cuff, glenoid retroversion limited to less than 15° and without previous shoulder surgery in spite of evidence in the literature that ATSA is successful in a much wider range of clinical and anatomic parameters. Although some may feel that these specific indications are too narrow, even with some modifications the percentage of ATSAs performed would not increase to a great degree. Given how RTSA now dominates the number of shoulder arthroplasty procedures performed, it is relevant to discuss cost. The cost of RTSA with 5 components (plus screws) is much greater than that of ATSA with 3 to 4 components. In 2020, the average selling price (ASP) for ATSA ranged from $4,091 to $6,717. For RTSA, the ASP ranged from $5,450 to $9,003.362021 hip and knee implant review.Orthop Netw News. 2021; 32 (Available at:): 8-9https://meeting.aahks.org/wp-content/uploads/ONN_2020_Hip_Knee.pdfGoogle Scholar This difference in ASP is meaningful because the implant cost is only a part of the cost of the entire episode of care. It becomes even more meaningful when considering the diagnostic-related group (DRG) payment provided by the Centers for Medicare & Medicaid Services (CMS) for performing total shoulder arthroplasty. These DRG payments do not differentiate between ATSA and RTSA. DRG 483, which includes upper extremity joint replacement, provides an average payment of $15,031 to institutions performing primary shoulder arthroplasty. This amount will vary depending on the geographic area as a product of the wage index specific for the area the service is provided.4Centers for Medicare & Medicaid Serviceshttps://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/wage-indexGoogle Scholar For DRG 483, this amount will vary from $7,791 (Aguadilla and Moca, Puerto Rico) to $11,575 (Sylacauga and Russellville, Alabama) to $24,271 (Vallejo, Fairfield, and Vacaville, California). This presents a financially disadvantageous position for the institutions and facilities where the procedures are performed on Medicare patients. When performed as ambulatory surgery, the average CMS reimbursement decreases to $13,048. This amount will also vary depending on the geographic locations as noted for inpatient Medicare cases: $7,469 (Puerto Rico) to $10,384 (Alabama) to $20,166 (California).4Centers for Medicare & Medicaid Serviceshttps://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/wage-indexGoogle Scholar Performing RTSA on Medicare patients as an outpatient procedure makes the finances even more challenging because the same implants are used at both sites of service. Addressing these financial issues is complex and requires either increasing CMS payments or decreasing the cost both of which are unlikely to change significantly. There is an additional point to raise. In 2007, Rockwood and others described RTSA as a “salvage” procedure. In 2023, this is clearly not the situation. However, it is important to consider the question: What is the “salvage” procedure for a failed RTSA? This is an important question to consider because as the number of RTSAs increase, the number of revisions will also increase. This is a trend that we learned for hip and knee replacement as these procedures were performed more frequently and in younger patients. The treatment of failed RTSA will be an ongoing challenge that we all need to address with increasing frequency using techniques that have been developed1Bodenorfer B. Loughran G. Looney A. Velott A. Stein J. Lutton D. et al.Short-term outcomes of reverse shoulder arthroplasty using a custom baseplate for severe glenoid deficiency.J Shoulder Elbow Surg. 2021; 30: 1060-1067https://doi.org/10.1016/j.jse.2020.08.002Abstract Full Text Full Text PDF Scopus (25) Google Scholar,5Chalmers P.N. Boileau P. Romeo A. Tashjian R. Revision reverse shoulder arthroplasty.J Am Acad Orthop Surg. 2019; 27: 426-436https://doi.org/10.5435/JAAOS-D-17-00535Crossref PubMed Scopus (53) Google Scholar,17Khan A. Luhringer T. Kohan E. Kowal L.L. Vaughan A. Zmistowski B. et al.Anatomic shoulder arthroplasty in Walch type C glenoid deformity: mid to long-term outcomes.J Shoulder Elbow Surg. 2023; 32: S23-S31https://doi.org/10.1016/j.jse.2023.02007Crossref PubMed Scopus (0) Google Scholar,23Levy J. Frankle M. Mighell M. Pupello B. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture.J Bone Joint Surg Am. 2007; 89: 292-300https://doi.org/10.2106/JBJS.E.01310Crossref PubMed Scopus (286) Google Scholar,28Rangarajan R. Blout C.K. Patel V.V. Bastian S. Lee B.K. Itamura J. Early results of reverse total shoulder arthroplasty using a patient-matched glenoid implant for severe glenoid one deficiency.J Shoulder Elbow Surg. 2020; 29S139https://doi.org/10.1016/j.jse.2020.04.024Abstract Full Text Full Text PDF Scopus (19) Google Scholar as well as those that will need to be developed in the future. Now that RTSA dominates the number of shoulder arthroplasty procedures performed each year, it becomes our responsibility to continue to refine the indications for the procedure, document the outcomes, understand the factors that predict successful outcomes and those that predispose to unsuccessful outcomes, and continue to refine the procedure and modify the implants used to improve outcomes. As a specialty, we are responding to this need. For 2010, a PubMed search for “reverse shoulder arthroplasty” lists 44 citations; for 2015, there were 178 citations, and in 2020, there were 329 citations, and for the past 12 months (as of August 1, 2023), there were 518 citations. This is the level of emphasis needed to optimize the results of RTSA. Our goals should also include producing lower cost implants to address the health care financing issues as challenging as that may be. As the number of shoulder arthroplasty procedures continues to increase each year, the impact of what we do for the patients we treat with RTSA only becomes increasingly more important.