A patient with arthritis usually experiences the progression of symptoms over time. At some stage, the patient may decide that the symptoms have reached a level of severity that leads him or her to elect to proceed with joint replacement; the authors refer to this degree of symptom severity as the “tipping point.” The patient-reported severity of the shoulder condition can be characterized by the preoperative Simple Shoulder Test.
Their goal was to study the factors that influenced the tipping point for 931 patients undergoing elective shoulder arthroplasty.
The preoperative Simple Shoulder Test (SST) score for all patients averaged 3.6 ± 2.7, but varied over a wide range.
The preoperative Simple Shoulder Test (SST) score for all patients averaged 3.6 ± 2.7, but varied over a wide range.
The average tipping points were different for the ream-and-run procedure (mean SST score, 5.0 ± 2.5), hemiarthroplasty(mean SST score, 3.1 ± 3.3), total shoulder arthroplasty (mean SST score, 3.0 ± 2.4), cuff tear arthropathy arthroplasty (mean SST score, 2.8 ± 2.5), and reverse total shoulder arthroplasty (mean SST score, 1.5 ± 1.8).
Differences were also noted for different diagnoses.
A number of other factors were significantly associated with a higher tipping point: younger age, better health, male sex, commercial insurance, married, nonuse of narcotics, use of alcohol, and shoulder problem not related to work.
The authors concluded that analysis of the tipping point—the patients’ self-assessed comfort and function at the point they decide to undergo shoulder joint replacement—provides a means by which we can better understand the factors influencing the indications for these procedures.
Comment: It is often stated that a shoulder arthroplasty is "indicated" for certain diagnoses. However, this study demonstrates that it is not the diagnosis that indicates the need for surgery, but rather the degree of functional loss perceived by the patient. Most patients proceeding with elective shoulder arthroplasty have lost more that half of the 12 functions of the Simple Shoulder Test, but the typical tipping point varies for different diagnoses and different procedures. Consideration of these data on the tipping points for a large number of patients is helpful in answering the question patients often as, "how will I know when it is time for me to have a shoulder replacement?"
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