Is there sufficient evidence to support intervention to manage shoulder arthritis?
The authors searched the literature published between 2002 and 2012 for Level 1 and 2 research studies concerning the management of shoulder arthritis to identify whether current management recommendations are adequate. As an indication of the lack of standardization in shoulder arthroplasty management, the authors point out that in the UK, the rates of TSA and hemiarthroplasty are approximately one-tenth and one-fifth the respective rates in the USA.
Sixteen studies met the inclusion criteria but they did not provide a clear indication of best intervention for shoulder arthritis.
The inclusion of a range of shoulder pathologies in some studies and the diversity in outcome measures used made it difficult for systematic reviews to effectively pool data. The outcome scales used in the studies varied widely, confounding comparisons between studies.
While better outcomes were reported with total shoulder replacement over hemiarthroplasty for shoulder osteoarthritis, the studies were often of limited quality. The type of glenoid component used in total shoulders employed had impact on revision rates, with 6.8% of TSAs with metal backed glenoids requiring revision compared to 1.7% of TSAs with polyethylene glenoids. For 'biological resurfacing' the overall complication rate was 13.3% and the re-operation rate was 26%, which was higher than the reported values for other treatment options.Sparse evidence was available for all other interventions, regardless of whether operative or non-operative.
The authors point to the need for standardization of outcome assessment following treatment of shoulder arthritis and find that more rigorous and robust primary studies are needed to guide clinical practice on the best interventions for arthritis of the shoulder.
Comment: The results of management for the patient with shoulder arthritis are influenced by the characteristics of the shoulder problem, the patient, the procedure and the physician performing the
procedure (the 4Ps). While the authors state that "determining the effectiveness of nonsurgical treatments, the optimal timing of surgical intervention and the effectiveness of surgical interventions would be best achieved by conducting large, multicentre randomized clinical trials," we suggest that such a process is unlikely to be put in place for many logistical, ethical and fiscal reasons. Instead we propose an approach that would increase the value of the commonly performed level III and Level IV studies: if each study provided in online appendix data for each case (including the characteristics of the shoulder problem, the patient, the procedure and the physician) as well as the outcome scale results before and after surgery, then the patients could be included as individuals in a combined analysis that would avoid the limitations of 'between study' comparisons.
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