Osteoarthritis with an intact rotator cuff, reverse shoulder arthroplasty, or total shoulder arthroplasty? : a qualitative study of surgeon decision-making.

Aims: The indications for reverse shoulder arthroplasty (RSA) have expanded beyond the primary design philosophy of an implant used to deal with rotator cuff deficiency. Its application in the cuff intact shoulder is growing in clinical practice. Despite this, there is little understanding of how surgeons decide between implants, specifically RSA and total shoulder arthroplasty (TSA) in this clinical scenario. Methods: Trauma & Orthopaedic Consultants specializing in shoulder surgery were recruited to participate in semistructured interviews by the research team. Using grounded theory methodology, the transcribed interviews were analyzed to generate themes and theories on factors affecting the decision-making between RSA and TSA. Collection and analysis was concluded when data saturation had been reached. Results: Patients characteristics, specifically 'physiological age', a term incorporating age, comorbid status, and preoperative function played a key role in decision-making. Anatomical factors specifically glenoid morphology and retroversion angle significantly contributed to implant choice; however, specific cut-offs for determining implants were not universal. Other themes identified included revision profiles of the implants, functional outcomes, and surgical training and experience. Conclusion: The decision-making between RSA and TSA for osteoarthritis and cuff intact patients is complex and multifactorial. The main factors surgeons consider are physiological age, patient anatomy, and functional outcomes. Within these factors however, there is no uniform agreement on which implant is best for which patients.