These authors reviewed 5670 primary shoulder arthroplasties (1833 anatomic total shoulder arthroplasties [TSA] and 3837 reverse shoulder arthroplasties [RSAs]) performed over a 10-year period to determine the tipping points for these procedures - that is the state of the shoulder just before arthroplasty as characterized by the preoperative range of motion, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, the Shoulder Pain and Disability Index score, and the Constant score.
They found that patients undergoing RSA demonstrated lower tipping points than TSA for all range-of-motion parameters as well as the Simple Shoulder Test, American Shoulder and Elbow Surgeons, Shoulder Pain and Disability Index. Female patients had lower tipping points prior to shoulder arthroplasty, regardless of implant type.
When the total shoulder arthroplasty subgroup was evaluated, both female sex and a higher body mass index were shown to be associated with a lower tipping point.
Comment: The common use of the Simple Shoulder Test enables a comparison of the tipping points found in this study to those reported in a prior study by Somerson et al (see this link). The comparison (see below) suggests the need to determine whether the observed differences are a result of different demographics or different thresholds for shoulder arthroplasties in the two practices.
Further detail on the Somerson study are presented below:
The “tipping point” for 931 elective shoulder arthroplasties
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. 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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A video of our approach to total shoulder arthroplasty can be seen by clicking this link.
A video of our approach to reverse shoulder arthroplasty can be seen by clicking this link.
A video of our approach to reverse shoulder arthroplasty can be seen by clicking this link.
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