Tuesday, April 19, 2016

Total shoulders and hemiarthroplasties - satisfaction and revision - are we comparing surgeries or patients?

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 30 of 227 primary HAs (11.9%) and 54 of 770 primary TSAs (7.0%) performed by two surgeons with a modular, anatomic shoulder prosthesis in patients aged 50 years or younger and with a minimum of 2 years’ follow-up. 27 of 30 HAs (90%) and 44 of 54 TSAs (81%) were available for follow-up evaluation.

The choice for glenoid component implantation was individualized for each patient 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. In general, the decision on the type of arthroplasty was made preoperatively regardless of glenoid morphology, and glenoid reconstruction was performed whenever possible. A shared decision-making process with the patients was performed, allowing them to decide which type of arthroplasty they would like to undergo.

The Kaplan-Meier patient satisfaction survival rates at 5 years were 71.6% for patients having HAs and 95% for patients having TSAs. Multivariable regression analysis implicated postoperative pain as the primary causative factor for failure of patient satisfaction in all patients. In contrast, the implant survival rates at 5 years were 89% for patients having HAs and 95% for patients having TSAs.

Interestingly, in this group of patients the preoperative glenoid type did not correlate with patient satisfaction.

Comment: While the authors conclude that "Primary TSA outperforms HA in both implant survival and patient satisfaction survival rates at short-term follow-up," it is apparent that the shoulders and patients receiving HA were different than those receiving TSA (see second paragraph above). That the patients were not the same can be seen from the observation that the percentage of males was 48% for HA and 70% for TSA and the percentage of patients with the diagnosis of osteoarthritis was 52% for HA and 75% for TSA.

The authors found that the rates of dissatisfaction with the outcome were greater than the revision rates. This is an observation that has made previously (see this link and this link). The reason for this discordance is apparent: a patient who is dissatisfied with the first surgery may be reluctant to submit to a revision or they may not have an easy time finding a surgeon willing to address their dissatisfaction with a second procedure. 


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