Monday, March 12, 2018

Which patients are at risk for not improving after a total shoulder replacement?

Risk factors for failing to achieve improvement after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis

These authors from a high volume shoulder center reviewed available two year followups on their patients having primary total shoulder arthroplasty for osteoarthritis between 2007 to 2013.

A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure.

Of the 459 of 699 arthroplasties that had followup data, 48 (10.5%) failed to achieve a desirable outcome. 

Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure to improve (P < .001).

The authors concluded that revious shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA.

Comment: This study is limited by the fact that followup information was only available for less than two thirds (459 of 699) of the patients meeting the inclusion criteria.  We can't know if the 33% lost to followup had revision surgery or worse or better outcomes than those who responded to request for followup. This study did not consider preoperative glenoid pathology  (i.e. glenoid type or glenoid version) or work relationship of the arthritis as a risk factors.

In spite of these limitations, this study suggests that even in expert hands one out of ten patients failed to achieve a desirable outcome from a primary total shoulder for osteoarthritis. In considering the risk factors identified:
(1) diabetes is a risk factor for postoperative stiffness and infection
(2) prior surgery is a risk factor for infection and altered surgical anatomy
(3) rotator cuff tear is a risk factor for weakness, pain and instability
(4) a high preoperative ASES score leaves less room for improvement by the minimal clinically important difference. 

Each of these points is worthy of discussion with patients considering total shoulder arthroplasty.

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