Friday, January 8, 2016

Shoulder arthroplasty: patient satisfaction vs. implant survival

Evaluation of satisfaction and durability after hemiarthroplasty and total shoulder arthroplasty in a cohort of patients aged 50 years or younger: an analysis of discordance of patient satisfaction and implant survival.

These authors reviewed their cases of primary hemi and total shoulder arthroplasty in patients 50 years or younger that had at least two years of followup, comparing clinical outcomes with component survivorship. Importantly, the choice between hemi and total shoulder arthroplasty was made by the surgeon  based on multiple factors including etiology of arthritis and coexisting anatomic factors, such as the structural  condition of the glenoid and decentering of the humeral head, as well as patient activity level. 

Patient satisfaction survival was based on yes or no answers to 2 binary questions regarding willingness to undergo surgery again and whether surgery improved the patient's shoulder. Multivariable regression analysis implicated postoperative pain as the primary causative factor for failure of patient satisfaction in all patients.

The Kaplan-Meier patient satisfaction survival rates at 5 years were 71.6% for hemiarthroplasties and 95% for TSAs.  The implant survival rates at 5 years were 89% for HAs and 95%.

Self-reported satisfaction declined for both procedures five or more years after arthroplasty while no patients had a revision after 2.5 years. The authors caution that studies and registries must incorporate measurements of patient satisfaction and not just revision rates to truly interpret outcomes.

Comment: The hemiarthroplasty and the total shoulder groups were not comparable, so that conclusions cannot be made regarding the relative effectiveness of the two procedures. For example only 48% of the hemiarthroplasties were in male patients while 70% of the total shoulders were in males (who are known to have better shoulder arthroplasty outcomes than females);  only 51% of the hemiarthroplasties were performed for osteoarthritis while 75% of the total shoulder arthroplasties were performed for osteoarthitis (which is known to have better outcomes than other diagnoses).

For this reason the authors' statement that "Overall, it appears that primary TSA outperforms HA in young patients in terms of implant longevity, patient outcomes, and cost-effectiveness" is not supportable by the data in this study.

"Implant survivorship" is a temptingly easy metric to use in studies of implant databases. However, as this paper demonstrates, the fact that the patients choose to retain their implant does not mean that they are satisfied with the clinical result. Perhaps they were unwilling to subject themselves to another surgery after the failure or they could not find a surgeon willing to perform a revision.

Since the goal of shoulder arthroplasty is to improve the patient self-assessed comfort and function of the arthritic shoulder, the most relevant outcome measure is the improvement in a metric such as the Simple Shoulder Test, rather than the patient's decision to avoid revision.

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