The authors of Do patients with poor early clinical outcomes after reverse total shoulder arthroplasty ultimately improve? reported the outcomes achieved by 36 different surgeons using the Exactech Equinoxe reverse total shoulder arthroplasty (rTSA) in the treatment of shoulder osteoarthritis, cuff tear arthropathy, or rotator cuff tear.
They found that 292 of 1477 (20%) of their rTSA patients had poor early recovery of shoulder shoulder comfort and function defined as an American Shoulder and Elbow Surgeons (ASES) score below the 20th percentile at 3 months (58 points) or 6 months (65 points) after surgery.
Persistent poor performance at 2 years was defined as failure to achieve the patient acceptable symptomatic state for rTSA (77.3 points for the ASES score). Early recovery was predictive of the two-year recovery: 61% of patients with poor performance at either 3- or 6-month follow-up had persistently poor performance at 2 years. The rate of poor performance at two years after surgery increased to 85% if early poor performance occurred at both 3- and 6-month follow-up.
On multivariate logistic regression analysis, independent predictors of persistent poor performance after rTSA included previous surgery on the affected shoulder, lower preoperative ASES score, and lower preoperative subjective rating of pain at its worst. Prior surgery led to a 2.14 times increased odds of persistent poor performance after rTSA. Persistent poor performers at 2-year follow-up in their study had poorer preoperative ASES scores compared with patients who eventually improved.
Comment: While it is understandable that patients with better preoperative function and those without prior surgery are more likely to achieve better outcomes after reverse total shoulder arthroplasty, neither of these are modifiable risk factors.
Persistent poor performance at 2 years was defined as failure to achieve the patient acceptable symptomatic state for rTSA (77.3 points for the ASES score). Early recovery was predictive of the two-year recovery: 61% of patients with poor performance at either 3- or 6-month follow-up had persistently poor performance at 2 years. The rate of poor performance at two years after surgery increased to 85% if early poor performance occurred at both 3- and 6-month follow-up.
On multivariate logistic regression analysis, independent predictors of persistent poor performance after rTSA included previous surgery on the affected shoulder, lower preoperative ASES score, and lower preoperative subjective rating of pain at its worst. Prior surgery led to a 2.14 times increased odds of persistent poor performance after rTSA. Persistent poor performers at 2-year follow-up in their study had poorer preoperative ASES scores compared with patients who eventually improved.
Comment: While it is understandable that patients with better preoperative function and those without prior surgery are more likely to achieve better outcomes after reverse total shoulder arthroplasty, neither of these are modifiable risk factors.
In the large database accessible to these authors, it would be of interest to seek risk factors that are potentially modifiable, such as which of the 36 surgeons performed the procedure and the size and positioning of the implants.
This study reveals that patients with poor shoulder comfort and function in the first 3 to 6 months after rTSA are at substantial risk for poor shoulder comfort and function at two years after surgery. This prompts the question: "in patients with poor early outcomes, what interventions might improve the long term outcomes?" Such an approach would require study of the possible elements of the poor early outcome in each patient:
?stiffness,
?weakness,
?pain,
?instability,
?stress reaction of the acromion/scapular spine,
?overlengthening,
?neurological issues.
?suboptimal positioning of implants
?notching
?inadequate fixation of the implants
Some of these factors may be modifiable, for example by more aggressive pain management, physical therapy, emotional support and, if indicated, revision of the arthroplasty.
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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).
