Thursday, October 22, 2015

Reverse total shoulder - what patients with massive cuff tears tend to poorly? What is the value?

Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

These authors conducted a retrospective case-control analysis to determine the risk factors for poor outcomes after reverse shoulder arthroplasty (RSA) for massive rotator cuff tear without glenohumeral arthritis. Cases (n=13) were defined as Simple Shoulder Test (SST) score improvement of ≤1, whereas controls (n=61) had improved SST score ≥2.

Neurologic dysfunction (P = .006), age <60 years (P = .02), and high preoperative SST score (7 or more) (P = .03) were independently associated with poor functional improvement.

Hospital costs were used as a proxy measure for the overall cost of the procedure. Direct hospital costs averaged $18,367 for cases vs. $16,585 for controls, and the indirect hospital costs averaged $6470 for cases vs. $5870 for controls. The total hospital costs for cases averaged $24,837 vs. $22,456 for controls.

The benefit of the procedure was characterized as the change in the ASES score. The value of RSA (ΔASES/$10,000 cost) for cases was 0.8 compared with 17.5 for controls (P < .0001). Thus the value of RSA was > 20 times higher for control patients than for cases.

Nine patients (12%) experienced a major complication:instability requiring multiple closed reductions with eventual resolution (n . 1), instability requiring revision (n . 1), and acromial fracture (n . 7). Four patients (5%) experienced a minor complication: lower extremity deep venous thrombosis (n . 1), reflex sympathetic dystrophy in the operative extremity that resolved (n . 1), wound dehiscence treated successfully with oral antibiotics only (n . 1), and postoperative aspiration requiring a longer hospital stay and temporary nasogastric tube insertion (n . 1). The total complication rate was 17%, with a 1.4% revision rate at minimum 2-year follow-up.

Comment: These data from a high volume RSA practice are helpful in guiding patient selection this procedure. While improvement of only 2 SST functions is a relatively low threshold for defining improvement, it is important that the authors used a patient self-assessment metric, such as the SST, in quantitating improvement in the preoperative comfort and function. The finding that individuals with high preoperative SST scores have on average less improvement is consistent with our observation with other types of arthroplasty and provides easy to obtain information that is useful in deciding whether or not surgery is appropriate in individual cases.

The data on value are of great interest. We want to spend health care dollars where they will do the most good. The value equation of change in comfort and function divided by the cost. If instead of the ASES score the authors use the SST, the Δ SST for the cases was be -1 and the Δ SST for the controls was 6.6. Using the total hospital costs for cases as $24,837 vs. $22,456 for controls, the value of the cases would be -0.4 SST/$10,000 for the cases and +2.96 SST/$10,000 for the controls.
Makes one think!


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