Mental toughness - how does it relate to longer term ream and run and total shoulder arthroplasty outcomes?

Shoulder arthroplasty provides a great opportunity for patients with arthritis to recover lost shoulder comfort and function. However, recovery from the operation may challenge the patients' mental as well as their physical toughness. There is evidence that resilience may be an important attribute in the recovery from shoulder surgery.

Several scales have been validated for assessing a person's resilience, including the Brief Resilence Scale

and the The Connor-Davidson Resilience Scale, which assesses the ability to adapt to change, to deal with whatever comes, to see the humorous side of things, to cope with stress, to bounce back after illness or hardship, to achieve goals despite obstacles, to stay focused under pressure, to avoid being discouraged by failure, to think of oneself as being a strong person, and to handle unpleasant feelings.

The authors of Anatomic Shoulder Arthroplasty: The Correlation between Patient Resilience, Mental Health, and Outcome studied 399 patients (195 ream and run (RnR) and 204 anatomic total shoulder (aTSA)) at a mean follow-up of 6.3 ± 3.3 years. 

In this study of anatomic arthroplasties, increased resilience and better mental health were correlated with better outcomes.

In univariable analysis, the Connor Davidson Resilience Scale-10 (CD RISC-10) at latest follow-up was positively correlated with postoperative Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Score (ASES) and satisfaction after both RnR and aTSA. Mean CD RISC-10 scores were higher in the RnR cohort (34.3 ± 4.8 vs. 32.5 ± 6.2 for aTSA, p<0.001). 

In the multivariable linear regression analysis, greater resilience was associated with better outcomes after anatomic total shoulder arthroplasty: CD RISC-10 was independently associated with postoperative SST, ASES and satisfaction scores in aTSA patients. 

Better mental health was associated with superior outcomes after the ream and run procedure: CD RISC-10 was correlated with satisfaction.Veteran’s RAND-12 Mental Component Score (VR-12 MCS) was correlated with ASES and satisfaction after RnR.

Comment: It may be useful for surgeons to get a sense of the patient's mental toughness before proceeding with surgery and to be sure that appropriate support is in place for those whose resilience may be challenged during post-arthroplasty recovery. 

see also

Is resilience a predictor of the outcomes of total shoulder arthroplasty?

Resiliency Influences Post-Operative Outcomes Following Rotator Cuff Repair

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

What predicts the value of shoulder joint replacement arthroplasty to the patient?

Development and Validation of a Predictive Model for Outcomes in Shoulder Arthroplasty: A Multicenter Analysis of over 2000 Patients

 

As the authors point out:

(1) Discussing the likely result of shoulder arthroplasty is an important part of the preoperative patient-surgeon conversation. 

(2) Setting a realistic expectations is important for achieving patient satisfaction. 

(3) Identifying risk factors for poorer outcomes may suggest approaches for addressing these factors before surgery.

 

They sought to develop a model to predict the 2-year American Shoulder and Elbow Surgeons (ASES) score in patients having shoulder arthroplasty using a set of preoperative patient factors and type of arthroplasty performed.

 

External validation was performed retrospectively by using 233 patients who had shoulder arthroplasty at a site that was not used to develop the model

 

Using their model, the mean difference between predicted and actual 2-year ASES score was 12.7 points. For 85% of patients the predicted ASES score was within published values for the minimal clinically important difference (MCID 13.5-21). Seven of the 26 variables included in this study—older age, higher preoperative ASES score, non-disability status, non-COPD status, alcohol use, anatomic rather than reverse total shoulder arthroplasty, and primary rather than revision shoulder arthroplasty—showed significant association with higher 2-year ASES scores.

Comment:

These authors used the 2-year ASES score as the measure of success of shoulder arthroplasty. 

A higher postoperative score was associated with a higher preoperative score – in other words the better a shoulder functioned before surgery, the better it functioned after arthroplasty. If the defining metric was the postoperative score, "better" outcomes could be achieved by selecting patients for arthroplasty that had higher preoperative ASES scores.

The value of a procedure to the patient is usually determined not by the postoperative score alone but rather by whether or not the preoperative score was improved by an amount equal to or exceeding the minimal clinically important difference (MCID).

In the hypothetical example below, a postoperative ASES score of 70 was achieved. However, because the preoperative ASES score was 60, the improvement did not exceed the MCID

 In this cohort of patients it would be of great interest to know which factors were associated with improvement in the ASES score by the MCID for the ASES score (13.5-21)

The type of surgery might be considered a “modifiable” factor. This model suggests that aTSA is associated with better outcomes than RSA. However, diagnosis was not considered among the variables in the model. Patients having anatomic arthroplasty (aTSA) typically have a different distribution of diagnoses than those having a reverse arthroplasty (RSA); thus, the difference in final ASES score may be more related to diagnosis rather than procedure.  As an example, for the patient with pseudoparalysis, an aTSA would not be expected to yield as good a result as an RSA.

The bottom line is that in assessing or predicting the benefit of a shoulder arthroplasty, it is important to understand the implications of different result metrics and to be sure that the most important patient and shoulder characteristics are included in the analysis. 

 How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

 

Primary reverse total shoulder - which patients do less well?

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty

These authors reviewed 137 patients who underwent reverse total shoulder (RSA) for degenerative joint disease (86), rotator cuff tear (28) or rotator cuff tear arthropathy (23) from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded.

Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. 

Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. 

 Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). The majority of these surgeries were attempts at cuff repair.

Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement. Patients in the lowest improvement group (bottom 30%) had a preoperative ASES score of 42±15 in comparison to the 70% with satisfactory improvement which had a preoperative ASES score of 26±12.

Comment: This is an important type of study in which an individual surgeon examines their own practice, comparing those patients who do well with those who do less well in their own hands. The observations then inform their subsequent decision making as well as increasing the quality of discussions with their future patients about likely outcomes.

A video of our approach to reverse shoulder arthroplasty can be seen by clicking this link.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder joint replacement - is experience the great teacher?

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty

These authors asserted that increased operative duration is associated with an increase risk of adverse outcomes and complications. They sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. They conducted a retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes).

They found that high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001).

Progression through a fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001).

Reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery were also associated with increased operative times.

Comment: Increased annual surgical volume has the potential not only for shortening surgical time, but also for improving patient selection, preoperative preparation, surgical technique, postoperative rehabilitation, and justifying a consistent patient-care team around the high-volume practice - all of which can contribute to improved outcomes.

The challenges for the prospective shoulder arthroplasty patient include:
(1) 'exactly what is a 'high volume surgeon?'
(2) 'how do I find a high volume surgeon?'
(3) 'in a high volume practice, will I get personalized attention?'
(4) 'what is the trade-off between the convenience of a local lower volume surgeon and the experience of a more distant higher volume surgeon'?

Some of these questions can be informed by a recent publication:

Distribution of High-Volume Shoulder Arthroplasty Surgeons in the United States: Data from the 2014 Medicare Provider Utilization and Payment Data Release.

These authors point out that high-volume TSA surgeons are reported to have superior outcomes. They studied patient access to these surgeons using 2012 Medicare Provider Utilization and Payment Data Public Use File (MPUPD-PUF). This data base provided volume and reimbursement data for procedures performed by individual physicians participating in Medicare. They studied surgeon prevalence, surgeon distribution, and factors associated with higher or lower surgeon prevalence in metropolitan areas. Data were extracted for all physicians who performed a minimum of 11 TSA procedures for Medicare beneficiaries

The MPUPD-PUF included 774 surgeons across the United States who performed an annual minimum of 11 TSA procedures covered by Medicare, with a combined total of 19,505 TSA procedures. The median annual number of Medicare service claims for TSA was 19 (range, 11 to 163), and the mean was 25 (SE, 0.7).

Of these surgeons, 45% practiced within major metropolitan areas with a population of >1 million. Surgeons who had completed an ASES fellowship had a higher volume of procedural claims (median, 26; range, 11 to 120) compared with other surgeons (median, 17; range, 11 to 163; p < 0.001). 

The distribution among major metropolitan areas was highly unequal, and more surgeons were present in cities with an ASES fellowship program.

This study points to the challenges that patients in certain geographical areas have in accessing surgeons who perform at least 11 shoulder arthroplasties per year.

An interesting question arises from the use of an annual case volume of ≥11 as the definition of a 'high volume' surgeon. Historically, 'high volume' has been defined arbitrarily:

Surgeon Experience and Clinical and Economic Outcomes for Shoulder Arthroplasty categorized surgeons according to the total number of procedures performed within the total 6 year ( 1994 to 2000) study period  with one to five procedures considered low volume; six to thirty procedures, medium volume; and more than thirty procedures, high volume.

The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty defined a 'high volume' surgeon as one who performed 5 or more cases per year.

This study defines 'high volume' as ≥ 11 cases per year. The number is creeping up.

Last month this article was published:

Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty

These authors used a database of 289,976 patients undergoing primary total knee arthroplasty from an administrative database, they applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision.

They identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. 

Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories without a 'bottom' in sight:

Revision rates followed a similar pattern.  This study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons.

The question then arises, 'if a high volume knee arthroplasty surgeon is defined as one performing ≥65 cases per year, shouldn't the same threshold apply to shoulder arthroplasty surgeons?' Is there any reason to believe that the annual number of cases of shoulder arthroplasty necessary to achieve and maintain excellence should be lower than that for knee arthroplasty? Is a shoulder arthroplasty easier to learn and master than a total knee?

It is apparent that the higher the standard for 'high volume', the greater the challenge of finding a high volume surgeon.  

Never the less, there is no denying the benefits of volume. More practice

increases the chances of a good result

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Reverse shoulder arthroplasty results - the good and the bad of MCID

Causes of poor postoperative improvement after reverse total shoulder arthroplasty.

These authors analyzed 150 patients who underwent reverse total shoulder arthroplasty (RTSA) from 2007 to 2013. Patients with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. Poor postoperative improvement was defined by the authors as a change in the ASES of less than 12 points using the standard deviation method (see this link). 20 patients had ASES score improvement < 12 points. 

Logistic regression revealed that male sex (adjusted odds ratio [OR], 7.9; P = .004), presence of an intact rotator cuff at the time of surgery (adjusted OR, 4.8; P = .025), depression (adjusted OR, 11.2; P = .005), a higher baseline ASES score (P < .001), and higher total number of medical comorbidities (P = .035) were associated with poor postoperative improvement after RTSA.

They concluded that evidence of better preoperative function, such as a higher baseline ASES score and intact rotator cuff at the time of surgery, correlated with poor postoperative improvement. In addition, male sex, depression, and total number of medical comorbidities also correlated with poor postoperative improvement. These results are similar to a prior study that used improvement of two in the Simple Shoulder Test as the metric for improvement (see this link).

Comment: This article again shows that the characteristics of the patient (sex, depression, comorbidities), as well as those of the shoulder (cuff integrity) have strong influences over the results of surgery.

When we talk about the results of surgery, we need to be careful to differential the outcome from the improvement (outcome-ingo). Consider the following hypothetical example of four patients having RTSA. The ingo is shown on the horizontal axis and the outcome on the vertical axis. The numbers to the left of the vertical lines indicate the difference between outcome and ingo.

The round patient and the square patient improved by the MCID used in this article and would be considered successes, but the diamond and triangle patients did not and would have been considered failures. Note however that the best outcomes were for the patients who did not improve by the MCID (the diamond and the triangle). Note also that better outcomes were observed for patients with higher ingos. We can only wonder which of the four patients would be most satisfied with the results of their surgery. This example shows the flaws in the use of MCID - (1) achieving the threshold value is likely to be less satisfactory if the ingo is low and (2) patients with a high ingo have a harder time achieving the MCID threshold for a success. In this study the baseline ASES scores were 53.7 ± 4.6 for the 'failure' group and  32.5 ± 1.6 for the 'non-failure' group. Interestingly, 68% of the "failure" group were satisfied with the outcome of surgery.

A complementary method for analyzing the results is to look at the amount of improvement (the outcome minus the ingo) divided by the maximal possible improvement (the maximum possible score  (100) minus the ingo).  Considered in this way, the round patient improved by 28% of the maximum possible in comparison to 44% for the square patient, 50% for the diamond patient and 100% for the triangle patient.

To us it seems easier to explain to a prospective patient that 'in the past patients having this procedure have regained an average of X% of their normal function back' as opposed to 'in the past Y% of patients have improved by the MCID'.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Rotator Cuff Book

Check out the new Shoulder Arthritis Book - click here.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Narcotics and shoulder arthroplasty outcomes - some answers and some questions

Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty.

These authors report on 224 TSAs performed for primary glenohumeral joint osteoarthritis with 2- to 5-year follow-up. Sixty patients with a history of preoperative opioid use for shoulder pain were compared with a control group of 164 patients. Preoperative opioid use was determined prospectively by asking, "Do you take narcotic pain medication (codeine or stronger) for your shoulder?"

Preoperative opioid use was significantly associated with female sex, chronic back pain, depression, increased pain, lower activity, lower strength, and less range of motion.

The magnitude of change between the groups from preoperatively to the most recent follow-up was similar for all measures and range of motion measurements.

There was a statistical difference between the 2 groups in terms of the number of satisfied patients (opioid group, 48 of 60 [80%] vs. nonopioid group, 149 of 164 [91%]; P . .03).

Comments:  As pointed out in prior posts, preoperative opioid use has been associated with worse clinical outcomes after total knee arthroplasty, spine surgery, and more recently reverse TSA.

Several questions arise:

(1) This study used a 'yes' or 'no' question to determine opioid use, does the amount of narcotic matter?

(2) How should these data be used in counseling patients and in surgical decision making?

(3) Is preoperative narcotic detoxification improve outcomes?

(4) How does preoperative narcotic medication affect postoperative pain management?

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Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Results of attempted arthroscopic cuff repair - do articles like this make us any smarter?

Prognostic factors for recovery after arthroscopic rotator cuff repair: a prognostic study

These authors studied a series of 30 patients having attempted arthroscopic rotator cuff repair using the Western Ontario Rotator Cuff Index as primary outcome and RAND-36, Constant-Murley score, and a shoulder hindrance score as secondary outcomes. The characteristics of the rotator cuffs are shown below

Patients were significantly improved at 3 months and 6 months after arthroscopic rotator cuff repair. In multiple regression analysis, no factors could be identified as prognostic of the quality of life after arthroscopic rotator cuff repair (measured with the Western Ontario Rotator Cuff Index). For the outcome variables RAND-36 (6 months, 1 year) and shoulder hindrance score (1 year), fatty infiltration Goutallier stages 1 and 2 and retraction grades II, III, and IV were significant predictors.

Comment:  

What can be learned from this small series is that the recovery after attempted cuff repair is progressive over the first year, with only 50% of the functional recovery having been achieved at 3 months. This is important in light of the article that assumed that workers would be back to work 28 days after attempted cuff repair.

In this study, no followup cuff imaging was performed, so the rate of failure of the repair and the relationship of repair failure to clinical outcome are unknown. 

A comprehensive analysis on the effect of prognostic factors on clinical outcomes and cuff integrity is discussed in this post.

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Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Patients taking narcotics before surgery often have poorer results from surgery

Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery.

These authors evaluated 583 patients having lumbar, thoracolumbar, or cervical spine surgery to treat a structural lesion. The preoperative opioid consumption was correlated with the patient-reported outcome measures at three and twelve months postoperatively.

56% (326 patients) reported some degree of opioid use before surgery. Preoperative opioid use was a significant predictor of decreased scores at three and twelve months postoperatively. Every 10-mg increase in daily morphine equivalent amount taken preoperatively was associated with a 0.03 decrease in the 12-Item Short-Form Health Survey physical component summary and mental component summary scores, a 0.01 decrease in the EuroQol-5D score, and a 0.5 increase in the Oswestry Disability Index and Neck Disability Index score at twelve months postoperatively. 

Higher preoperative Modified Somatic Perception Questionnaire and Zung Depression Scale scores were also significant negative predictors.

Comment: Patients that take narcotics before surgery have a substantially increased risk of a poor outcome as well as increased preoperative risks. We have previously posted a similar finding for patients having total knee arthroplasty. Another post reviews the relationship among preoperative pain, depress and the severity of arthritis. It is important to evaluate and consider the preoperative use of narcotics and the presence of depression in the decision of if and when to carry out elective surgery, even if the patient has 'a structural lesion'.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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To see other similar posts, click on the label of interest below.

Preoperative confidence predicts the outcome of shoulder arthroplasty - attitude is everything

Patient Pre-operative Confidence in Outcome Predicts Functionality after Total Shoulder Arthroplasty

These authors suggest that a patient’s pre-operative mental state may play an important role in the patient’s functional outcome after surgery. They sought to determine if a patient’s confidence in their ability to return to the level of activity desired after total shoulder arthroplasty would influence their post-operative functional scores.

Patients undergoing a primary total shoulder were required to complete a pre-operative questionnaire that included their demographics, body mass index, Penn Shoulder Score, SF-12 and their confidence in reaching their level of desired functionality post-operatively (scored 0-10). 

Patients then completed an identical post-operative questionnaire at their follow-up visits. 

Of 499 patients eligible, questionnaires were completed by 347 patients at an average follow up of 550 days. Cohort population average age was 66.4 years, females comprised 41.5% and the average BMI was 30.3. Patients had a high level of confidence that their outcome would match their expectations, with an average score of 7.8 (standard deviation = 2.2, range 0-10). For every one point increase in confidence, patients experienced an average increase in their function score of 2.9 (95% confidence interval: 1.1, 4.7; p=0.001) and improvement in their pain score of 1.4 (95% CI: 0.2, 2.5; p=0.021) according to the Penn Shoulder Score. 

Comment: The patient’s pre-operative confidence in their ability to attain their desired post-operative functional outcomes is a significant predictor of the patient’s outcome. Patients with greater pre-operative confidence actually have better post-operative functional outcomes than their less confident peers. Surgeons should be reluctant to offer surgery to individuals who lack confidence in a positive outcome.

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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

The Effects of Nutritional Deficiencies, Smoking, and Systemic Disease on Orthopaedic Outcomes

The Effects of Nutritional Deficiencies, Smoking, and Systemic Disease on Orthopaedic Outcomes

These authors point out that correctable risk factors can be identified before elective surgery.
Nutritional risk factors include total lymphocyte count, serum albumin <3.4 g/dL, prealbumin <3.5 g/dL, serum zinc <95 micrograms/dL, and vitamin D <20 ng/mL.

They state that when the Rainey-MacDonald Nutritional Index, or the total of  1.2 X serum albumin + .013 X serum transferrin - 6.43 is 0 or less, there is likely to be nutritional depletion. Alternatively when the total of 1.489 X albumin (g/dL) + 41.7 X body weight/ideal body weight is less than 92, there is a risk of nutritional deficiency.
Smoking has been documented to increase the risk of bone and soft tissue healing problems, cardiopulmonary complications, surgical complications, deep venous thrombosis, infection, and dissatisfaction with the results of surgery.
Pulmonary disease, including pulmonary hypertension and obstructive sleep apnea are also associated with increased surgical risk.
They point out that these risk factors are modifiable and attention should be directed at them before elective surgery.

We suggest that other factors that could be added to this list include depression, chronic opioid use, and obesity.

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Consultation for those who live a distance away from Seattle.

**Check out the new Shoulder Arthritis Book - click here.**

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Relationship of low income to surgical outcome

Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty.

In past posts we discussed the "4Ps" that influence the result of surgery: the Problem (e.g. arthritis or massive cuff tear) , the Patient with the problem (e.g. age, gender, smoking, socioeconomic factors) , the Procedure to be performed (e.g. hemiarthroplasty, reverse total shoulder) and the Physician performing the procedure (e.g. extent of training, annual volume of similar cases).

This article focuses on the second P, socioeconomic factors and their relationship to the results of total knee replacement in young patients. The authors surveyed 661 patients 1 to 4 years after primary TKA for noninflammatory arthritis. While this study concerns total knees, its findings are likely to hold true for elective surgery as well.

They found that patients reporting incomes of less than $25,000 were less likely to be satisfied with  outcomes and more likely to have functional limitations than patients with higher incomes. At a lower level of association, women and minority patients were more likely to have functional limitations. Employment status and educational level at the least impact on satisfaction and function. The choice of implant did not have a significant effect on the outcome of surgery.

While much of our literature focuses on the type of procedure and the choice of implant, this study clearly demonstrates that the second P - the patient - has a strong influence on the result. Or as Osler said, "It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has."

The reasons behind the association of low income with poorer outcome are as yet unknown. Readers may wish to visit a recent post regarding the relationship between revision and type of insurance. 

In an age of 'pay for performance', it will be essential that the incentives placed on good performance do not create an incentive to inappropriately avoid treating patients with lower incomes or those on Medicare and Medicaid.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


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