Friday, March 3, 2023

Risk factors for adverse outcomes after shoulder arthroplasty

It is being increasingly recognized that patient characteristics - rather than shoulder characteristics - are the most important factors in determining the outcome of shoulder arthroplasty. For example, a recent article, Comparison of reverse shoulder arthroplasty and total shoulder arthroplasty for patients with inflammatory arthritis, pointed to the challenges of managing the shoulder with rheumatoid arthritis: high rates of cuff tear with anatomic arthroplasty and high rates of acromial and spine fractures after reverse total shoulder.

The authors of Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty, considered another set of patient characteristics that have a strong influence on patient outcome after arthroplasty: poor education, poverty, and social deprivation and adverse environment. They compared revision rates of 5190 patients with these social determinants of health (SDOH) to 5190 matched patients without.

Economic disparities made up 89.2% of the SDOH cohort, followed by social (14.3%), environmental (8.0%), and educational (1.9%), although it is evident that some or indeed all of these may co-exist in a given patient.

Compared with the control cohort, SDOHs were associated with almost twice the risk of major complications as well as increased rates of minor complications, readmissions, and ED visits.

SDOHs were also associated with increased risks of aseptic loosening, instability, and ipsilateral revision as well as increased length of stay and costs of care.

Comment: One of the important aspects of this study is that it used adverse events as the primary outcome of interest in a defined patient population. This measure is not subject to the problem of patients lost to followup which confounds clinical followup studies and systematically excludes patients who are educationally, financially and socially compromised.

It teaches us that considering shoulder arthroplasty in each individual requires an understanding of three "E"s: education, economics and environment. Those with compromised social determinants of health require special attention to the advisability of proceeding with arthroplasty and to anticipating and planning to mitigate the risks of medical and surgical problems. The surgical team has the responsibility for taking extra time and care to communicate these concerns to the patient and their family before surgery, recognizing limited health literacy. This may be challenging in patients with lower levels of education or for whom English is not their primary language. Equally important is assuring that the patient has enhanced social support following surgery coupled with careful surveillance for possible adverse events.

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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).