While this paper is about knees, its substance is relevant to important questions about shoulder arthroplasty: what is a good result and how can it be predicted?
A "good outcome" at 5 years was defined in two ways:
(1) as an improvement in scores of greater than or equal to the minimal clinically important difference (MCID) in the primary analysis. The MCID for the OKS was 5, and the MCID for the PCS was 10.
(2) as an OKS of <30 and a PCS score of >50.
Age and preoperative Knee Society score (KSS) were found to be significant predictors.
When outcomes were assessed by the MCID, lesser age and lower (worse) preoperative KSS predicted a good outcome at 5 years.
When outcomes were assessed by absolute criteria (postoperative scores measured against OKS and PCS thresholds), a higher (better) preoperative KSS predicted a good outcome at 5 years. The effect of age was not significant.
Body mass index, preoperative flexion range, SF-36 mental component summary (MCS) score, mechanical alignment, sex, education level, ethnicity, operative side, number of comorbidities, type of anesthesia, and type of implant were found not to be significant predictors.
The authors concluded that the majority (85%) of their patients with osteoarthritis had good outcomes according to the MCID criterion and benefitted from primary TKA.
Older patients with a lower (worse) preoperative KSS can be informed that they have a high likelihood of improvement but a lower likelihood of achieving as good a functional outcome as those with better scores.
Comment: This paper is informative.
First, many of the factors that one might think would infuence the quality of the result did not have a significant effect (BMI, preoperative flexion range, SF-36 mental component summary (MCS) score, mechanical alignment, sex, education level, ethnicity, operative side, number of comorbidities, type of anesthesia, and type of implant).
Second, they showed that patients who were more functional before surgery realized the best function after surgery, whereas those who were less functional before surgery realized the most improvement.
These outcomes can be emulated by the chart below that uses data for three hypothetical patients.
We will all agree that the patient represented by the circle did poorly (as would be the case for any patient below the line). But did the diamond patient or the square patient get the better result? The diamond patient improved more but the square patient wound up with 90% of normal function and improved by half of the preoperative functional deficit (whereas the diamond improved only 33% of the preoperative functional deficit).
Rather than arguing whether the amount of improvement or the absolute value of the postoperative function is better, we should acknowlege that both may be useful in explaining the likely result of surgery to the patient.
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