CE Shoulder Arthroplasty

An Analysis of Data From the German Federal Statistical Office, 2010–2021

With the rising proportion of older persons in the population the risk rises for indications that require a total shoulder replacement surgical procedure (STEP). Primary STEP in osteoarthritis of the shoulder is being carried out by means of anatomical endoprostheses (anatomical total shoulder arthroplasty, aTSA). The objective is the restoration of the normal anatomy as much as is possible; the prerequisite for that is an intact and functioning rotator cuff. Reverse total shoulder arthroplasty (rTSA) is classically used in a scenario of a lacking or dysfunctional rotator cuff and severe bone defects of the glenoid with posterior decentering (1). In recent years additional indications for rTSA have developed subsequent to its use in proximal humerus fractures and irreparable rotator cuff lesions. All listed indications for STEP are affected by changes to the population structure, and this entails medical treatment too. We aimed to study the current healthcare situation as regards shoulder arthroplasty in Germany in relation to the population structure in the time period 2010–2021.

Methods

We retrospectively analyzed data from the German Federal Statistical Office and for the notified relevant codes of the OPS (Germany’s operation and procedure classification system). To evaluate annual case numbers in absolute terms as well as in relation to the actual size of the population groups we combined the data sources. To determine the incidence of the implantation of STEP in Germany from 2010 to 2021 we adjusted the data.

Results

The number of primary shoulder implants per year in Germany rose from 2010 to 2021 by +73% (anatomic –55%, reverse +308%) (Table, Figure). Relative to 100,000 population (incidence) the following change was observed: an increase in primary STEP by +71%, a decrease in aTSA by –56%; an increase in rTSA by +301%. In 2010, 46% of rTSA was used in persons older than 75; in 2021 this applied to 78%. In 2010, 25% of all STEP were implanted in persons younger than 55. in 2021 it was only 12%. In 2010, 62% of all aTSA were implanted in persons older than 70 and only 14% in those younger than 55; in 2021 the proportions were 34% and 16%. In 2010, 78% of rTSA were implanted in persons older than 70 and only 2% in those younger than 50. This ratio remained almost unchanged in 2021. Most of the increased incidence of rTSA was in the age groups older than 70; the decline in aTSA started in the age group older than 55 and is strongest in the group older than 80 (Table, Figure). During the study period, a measurable change occurred in the population proportions: the group of 41–55 year olds shrank in relative terms (24.4% versus 19.5%), whereas the group of 56–70 year olds grew (17.7% versus 21.4%. The age distribution of the incidence of STEP implantation has, however, not changed much: numbers rise steeply after the 60th year of life, peak in the group aged 81–85, and then fall.

Figure

Shoulder replacement implants/100 000 population in Germany in 2010 versus 2021

Table

Number and incidence of implanted shoulder arthroplasties by age groups in Germany in 2010–2021

Conclusion

The number of shoulder replacement surgical procedures has increased in number over the past 12 years, with the biggest rate of rTSA in the group older than 70 years. The numbers for aTSA are declining, especially in the age group >65 years (-15%). Part of the observed increase—which is notable even if corrected for 100,000 population in a setting of a slightly growing total population—can be explained with the changed population structure. The baby boomers are moving into the older age groups. The proportion of older and very old patients in the total population has therefore increased. A crucial proportion of STEP implantations affects exactly these two groups. The increase in the incidence of rTSA by 308% can, however, not be solely explained with the shift from aTSA to rTSA and the changed age structure of the population. Two important trends can be observed (2): On the one hand, treatment of proximal humerus fractures (among the most common fractures in older persons in terms of numbers) with rTSA has increased, with confirmed effectiveness of cost-benefit. And on the other hand, widening the indication for rTSA in older persons with irreparable rotator cuff lesions has become increasingly accepted, even in the absence of advanced osteoarthritis of the shoulder (1, 3). In the international comparison, a rise in case numbers also transpires for comparable industrialized nations. The supply situation in Germany is very high, with a mean incidence of 31/100,00 population; in England, Wales, Northern Ireland, and the Isle of Man, for example, the mean incidence was only 11/100,00 in 2022 (4). In view of the socioeconomic importance of the changes, shoulder replacement registries are becoming increasingly important as an instrument for quality assurance and as an early warning system for complications and suspicious implants (5).

Matthias Aurich, Daniel P. Berthold, Jan Theopold, Bernd Bittersohl, Milad Farkhondeh Fal, Felix Krane, Jörn Kircher

Department of Orthopaedics, Trauma, and Reconstructive Surgery, Halle University Hospital, Halle (Saale), Saxony-Anhalt, Germany (Aurich)

Department of Orthopaedic Sports Medicine, Technical University of Munich, Munich, Germany (Berthold)

Department of Orthopedic Surgery, Traumatology and Plastic Surgery, Leipzig University, Leipzig, Germany (Theopold)

Klinikum Bielefeld – Mitte, Department of Orthopedics, Bielefeld University Hospital (Bittersohl)

Department of Trauma and Orthopaedic Surgery, University Hospital Hamburg Eppendorf, Hamburg, Germany (Farkhondeh Fal)

Faculty of Medicine and University Hospital, Center for Orthopedic, Trauma and Plastic Surgery, University of Cologne, Cologne, Germany (Krane)

Department of Shoulder and Elbow Surgery, ATOS Klinik Fleetinsel Hamburg, Hamburg, Germany (Kircher), [e-mail]

Acknowledgments

We thank the committee for osteoarthritis of the shoulder in the AGA (Society for Arthroscopy and Joint-Surgery) and the Commission Replacement Registry in the DVSE (the German, Austrian, and Swiss Shoulder and Elbow Society, reg. assoc.) for their support.

Conflict of interest statement

JK received consultancy fees (advisory board) and/or lecture honoraria and/or travel expenses and/or appraiser fees from Waldemar Link GmbH and Limacorporate SPA. He is the chair of the Commission Replacement Registry in the DVSE and the AGA committee for osteoarthritis of the shoulder as well as joint editor/publisher of the journals JSES and Arthroscopy.

The remaining authors declare that no conflict of interest exists.

Manuscript received on 23 February 2024, revised version accepted on 16 July 2024.

Translated from the original German by Birte Twisselmann, PhD.

Cite this as:
Aurich M, Berthold DP, Theopold J, Bittersohl B, Farkhondeh Fal M, Krane F, Kircher J: Shoulder arthroplasty—an analysis of data from the German Federal Statistical Office, 2010–2021. Dtsch Arztebl Int 2024; 121: 882–3. DOI: 10.3238/arztebl.m2024.0154

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