Total shoulder arthroplasty: tipping points, prognostic factors and outcomes

Surgeons and patients are interested in the factors predictive of outcome after total shoulder arthroplasty. The authors of Disease diagnosis and arthroplasty type are strongly associated with short-term postoperative patient reported outcomes in patients undergoing primary total shoulder arthroplasty conducted a large observational study of 1,042 patients having primary TSA at a major academic center with one-year follow-up documented by patient reported outcome measures (PROMS).  30% had reverse total shoulders (rTSAs) for cuff tear arthropathy (CTA), 26% had rTSAs for osteoarthritis (OA), and 44% had anatomic total shoulders (aTSAs) for OA. The decision to perform aTSA or rTSA for OA was apparently left to discretion of the individual surgeon. No patient in this study had an aTSA for CTA. 

Lower one-year PROMS scores were most prominently associated with a diagnosis of CTA, lower preoperative mental health and workers compensation insurance. Other negative factors included younger age, female sex, current smoking, chronic pain diagnosis, history of prior surgery, lower baseline PROMS, absence of glenoid bone loss. Of note, none of these factors are modifiable by the surgeon. Surgeon controlled variables, such as the implant selected and operative technique were not presented.

The authors found that patients that had to be excluded from analysis because they failed to provide 1 year PROMs were more likely to have a diagnosis of CTA, to be younger, to have race other than white, to have more comorbidities, to have less education, to inhabit areas of higher area deprivation index, to have lower baseline PROMS, to have more preoperative opioid use, and to have more chronic pain or psychiatric diagnoses. First year complications and revisions were not presented.

Comment: This is a carefully done observational study on a large number of total shoulder arthroplasties performed at a leading academic medical center. The authors provide the classic figure one, showing numbers of patients excluded and the reasons.

Graphical displays of the data from their Table 3 are shown below for both the American Shoulder and Elbow Surgeons score and the Penn Shoulder Score

`Several observations can be made from these charts:

(1) The Penn Shoulder Score data are essentially the same as the ASES data

(2) The tipping point (the average score prior to surgery (see What's the right time to have a shoulder joint replacement arthroplasty? When is it "indicated"? for each of the three groups was the same: 30 points. In other words, patients with OA or CTA turning to arthroplasty typically had only 30% of the patient reported outcome measure.

(3) Both the 1 year score and the percent of maximum possible improvement (see How can we measure whether our patients have benefitted from treatment? Problems with the MCID; benefit of %MPI) were lower for shoulders having cuff tear arthropathy than those having osteoarthritis; whereas the results for patients with OA were essentially the same whether the surgeon chose to perform an aTSA or a rTSA.

(4) No surgeon-controlled variables were identified that correlated with outcome.

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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).

Reverse total shoulder - when should it be done?

Reverse Total Shoulder Arthroplasty for Patients with Minimal Pre-Operative Pain: A Matched Cohort Analysis

 These authors point out that previous studies have demonstrated young age, high preoperative function, and neurologic dysfunction to be predictors of poor functional improvement after a reverse total shoulder arthroplasty (RSA), but that there is little known about the RSA outcomes for patients electing to have RSA for function more than pain.

They conducted a retrospective matched-cohort study on 260 RSA patients treated by an individual surgeon with a minimum 2-years follow-up.  195 patients had at least moderate baseline pain (“Function+Pain”), pre-defined by existing literature as a Visual Analog Scale (VAS) pain score > 3, were matched 3:1 with 65 patients based on gender, indication, and age to those with a minimal pain with VAS score ≤ 3 (“Function”). 

Patients in both groups showed no differences in most recent postoperative function,  overall improvement in functional scores, and active motion. 

However, pain scores improved only for patients with at least moderate baseline pain.

The Function cohort also had worse percent of maximal SST and ASES  improvement, and a lower proportion of these patients exceeded the threshold in percent of maximal improvement that predicts an “excellent” outcome.



Patient satisfaction was significantly different, as 10.8% of patients who elected to have RSA for loss of function alone were unsatisfied.

The authors concluded that RSA patients with minimal preoperative pain achieve significant improvements in function and motion similar to those who choose to have RSA for both pain and function, but are less satisfied and are less likely to achieve an “excellent” outcome.

Comment: This interesting study points out that patients who have a reverse total shoulder because of shoulder pain AND loss of shoulder function realize greater improvement and are more satisfied than patients who have a reverse total should because of the loss of shoulder function alone. 

Recently there has been interest in the Simple Shoulder Test (SST) "tipping point" at which point patients decide to proceed with a reverse total shoulder (see this link). 

The list of SST questions is shown below.

 

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'

Reverse total shoulder - is the tipping point changing?

A 10-year experience with reverse shoulder arthroplasty: are we operating earlier?

The concept of the "tipping point", i.e. the degree of disability a patient has when they decide to proceed with surgery, was introduced in the article published two years ago:  "The “tipping point” for 931 elective shoulder arthroplasties", see this link. In that article the mean Simple Shoulder Test (SST) tipping point for reverse total shoulder arthroplasty (RSA) was 1.5 ± 1.8.

The authors of the current article reviewed a total of 3975 primary RSAs performed over a 10-year period were retrospectively reviewed from a multi-institutional database. They found that the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Simple Shoulder Test and the Constant score remained similar over the 10-year study period, with all demonstrating slightly higher tipping points later in the study. ROM measures all showed small increases over time, demonstrating better ROM before electing to undergo RSA in later years.

Comment: It is of interest that the SST tipping point values in this paper are substantially higher than those of the original article referenced above). This indicates that there is substantial variation among practices in the degree of disability experienced by the patient before a reverse total shoulder is applied.  The tipping point provides a useful metric for characterizing and understanding these inter practice differences.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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

To see our new series of youtube videos on important shoulder surgeries and how they are done, 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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulders - which patients are satisfied?

Predictors of patient satisfaction after reverse shoulder arthroplasty

These authors sought to determine patient satisfaction and to identify predictors of satisfaction at two years after reverse shoulder arthroplasty (RSA) in 161 patients.

Improvements in ASES, Shoulder Activity Scale, VAS pain, and SF-12 physical component summary scores were associated with higher satisfaction.

On multivariate analysis, patients with higher preoperative ASES scores were less satisfied after surgery. In addition, patients with worse VAS fatigue and SF-12 mental and physical component summary scores preoperatively had lower satisfaction. 

Comment: This paper is instructive. First of all, it shows that patient factors (such as those measured by the SF-12 mental health and VAS fatigue scores) play heavily into the patients' satisfaction with this procedure (and probably with most other procedures as well).  Along with the problem, the procedure and the provider, the patient is one of the 4 Ps that determine the result of treatment.  

Secondly, while the means and medians are interesting, the variation is even more interesting as shown in the chart below. Patients with a preoperative ASES score of 100 have little room for improvement and are unlikely to be satisfied with surgery (see this link). Some patients experienced a drop of 64 points in their ASES score; these folks are likely to be unsatisfied.

Thus we come to the "tipping point"for  reverse total shoulders (see this link), i.e. when is it time to do this surgery. As shown in the link above, a recent study found that the tipping point for reverses was an ASES score of 38, a value approximately the same as the average preoperative ASES score of 35 in this paper.

The take away point is that surgeons should be cautious about offering elective surgery to patients with high levels of preoperative self-assessed comfort and function as well as those who have poor mental and physical health.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

=====

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'

When is it time to do a total shoulder or a reverse?

Defining the tipping point for primary shoulder arthroplasty

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 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.

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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'

What's the right time to have a shoulder joint replacement arthroplasty? When is it "indicated"?

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 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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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 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'