Revision rates following total shoulder arthroplasty in rural and urban hospitals : an Australian Orthopaedic Association National Joint Replacement Registry analysis of high-volume surgeons.

Abstract

Total shoulder arthroplasty (TSA) outcomes may be affected in rural settings where resources can differ from urban hospitals. This study compared revision rates of primary TSA performed in rural and urban hospitals analyzed from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) between 1 January 2008 and 31 December 2023. Rural and urban hospital location was defined by nationally accepted criteria. We included high-volume surgeons (upper two quartiles and undertook TSA in both settings) stratified for anatomical or reverse shoulder arthroplasty, and glenoid morphology. The cumulative percent revision (CPR) was determined using Kaplan-Meier estimates of survivorship and hazard ratios (HRs) from Cox proportional hazard models adjusted for age and sex. A total of 16,179 TSA procedures were performed; 3,456 (21%) in rural and 12,723 (79%) in urban hospitals. CPR at five years was 4.1% (95% CI 3.4 to 4.9) for rural TSA and 5.5% (95% CI 5.0 to 6.0) for urban hospitals. Rural hospitals had lower overall revision rates compared with urban hospitals (entire period, HR 0.81 (95% CI 0.66 to 0.99); p = 0.037). There was a higher rate of revision for primary anatomical TSA in rural centres for the first six months, followed by lower rates of revision (rural vs urban 0.6 months, HR 2.04, p = 0.011; six months to 1.5 years, HR 0.52, p 0.008; 1.5 years +, HR 0.36, p < 0.001). The revision rate for primary reverse TSA did not differ between rural and urban hospitals (entire period, HR 0.87, p = 0.233). Patients aged < 65 years had a lower revision risk in a rural hospital, but there was no difference in patients aged > 65 years. Sex did not change TSA revision rates in rural and urban hospitals. Revision rates for TSA procedures performed in rural hospitals were equivalent to urban hospitals. Our study supports the provision of TSA services in rural hospitals when undertaken by high-volume surgeons.