Monday, March 24, 2014

Shoulder arthroplasty registries, what do they tell us and what do they not tell us?

Patient-reported outcome and risk of revision after shoulder replacement for osteoarthritis1,209 cases from the Danish Shoulder Arthroplasty Registry, 2006–2010

These authors used patient-reported outcome and risk of revision for hemiarthroplasty vs. total shoulder arthroplasty and for stemmed hemiarthroplasty vs. resurfacing hemiarthroplasty in patients with glenohumeral osteoarthritis.

They included all patients reported to the Danish Shoulder Arthroplasty Registry between January 2006 and December 2010. 1,209 arthroplasties in 1,109 patients were eligible. Western Ontario Osteoarthritis of the Shoulder index (WOOS) was used to evaluate patient-reported outcome 1 year postoperatively. Revision rates were also tabulated.

 There were 113 total shoulders and 1096 hemiarthroplasties (837 resurfacing and 259 stemmed). Patients treated with total shoulder generally had a better WOOS scores.  There were no statistically significant differences in revision rate or in adjusted risk of revision between any of the groups.

Comment: Registries are of interest, but there are inherent problems in interpreting the data. For example in this sample, there were almost 10 times as many hemiarthroplasties as total shoulders. This prompts us to ask 'what factors resulted in patients getting a total shoulder?' - was it the more experienced surgeon, a healthier patient, better shoulder anatomy, or what? For example, it is of interest that 21% of the patients having hemiatrhoplasty had had prior surgery whereas only 12% of those having total shoulders had had prior surgery. It is well recognized that prior surgery is a major risk factor for a less successful outcome.

What would have been a more useful analysis would be the comparison of those shoulders with a good result with a given type of arthroplasty to those with a poor result for the same procedure. In that analysis the factors leading to the decision of arthroplasty type would be controlled so that the authors could evaluate the effects of sex, age, prior surgery, diagnosis, comorbidities, and surgeon experience (i.e. the 4Ps).


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