Does diabetes affect functional outcomes after shoulder arthroplasty?

Reverse Shoulder Arthroplasty Patients Younger Than 60 Years Old Exhibit Lower Clinically Significant Single Assessment Numeric Evaluation (SANE) Scores Compared to Older Patients

INTRODUCTION

The incidence of reverse shoulder arthroplasty (RTSA) in the United States has increased. Patients under 60 years old with failed rotator cuff repairs or degenerative joint disease with glenoid deformity may be candidates for RTSA and contribute to this increase. The single assessment numeric evaluation (SANE) score is a reliable post-operative scoring technique when compared with other post-operative measures. This study aimed to compare the effect of age on the likelihood of reaching clinically significant SANE scores following RTSA.

METHODS

A multicenter retrospective review was performed with a consecutive series of RTSA from December 2015 to September 2021. Patients were stratified into groups based on their age at the time of operation: (1) less than 60 years old, (2) 60-69 years old, (3) 70-79 years old, and (3) greater than 80 years old. The proportions of patients in all cohorts reaching and surpassing clinically significant thresholds at each visit were determined. Likelihood ratios were determined for each age cohort to compare the likelihood of reaching clinically significant SANE scores.

RESULTS

A total of 292 of 885 (33%) patients had completed survey data over two years and were included in the study. The 70-79-year-old group was 3.152 (p=.035) times more likely to achieve minimal clinically important difference (MCID) and 2.125 (p=.048) times more likely to achieve patient-acceptable symptomatic state (PASS) compared with patients <60 years old. The cohort who was 80+ years old was also 4.867 (p=.045) times more likely to achieve MCID compared to the <60-year-old cohort. The <60 cohort had the lowest proportion of all patient cohorts achieving MCID.

CONCLUSION

A lower proportion of patients younger than 60 years old undergoing RTSA achieved clinically significant post-operative SANE scores. The 70-79-year-old age group was more likely to reach MCID and PASS, and the patients who were 80+ years old were more likely to reach MCID compared to patients younger than 60 years old.

Diabetes increases risk for readmission and infection after shoulder arthroplasty: A national readmissions study of 113,713 patients

Background

The recent increasing popularity of shoulder arthroplasty has been paralleled by a rise in prevalence of diabetes in the United States. We aimed to evaluate the impact of diabetes status on readmission and short-term complications among patients undergoing shoulder arthroplasty.

Methods

We analyzed the Healthcare Cost and Utilization Project National Readmissions Database (NRD) between the years 2016-2018. Patients were included in the study if they underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) according to ICD-10 procedure codes. Postoperative complications including surgical site/joint infection, dislocation, prosthetic complications, hardware-related complications, non-infectious wound complications, 30-day, and 90-day readmission were collected.

Results

A total of 113,713 shoulder arthroplasty patients were included. 23,749 (20.9%) had a diagnosis of diabetes and 89,964 (79.1%) did not. On multivariate analysis, a diagnosis of diabetes led to an increased risk of 30-day (OR: 1.24; 95% CI: [1.14, 1.34]; p < 0.001) and 90-day (OR: 1.18; 95% CI: [1.12, 1.25]; p < 0.001) readmission, surgical site/joint infection (OR: 1.21; 95% CI: [1.06, 1.38]; p = 0.005), respiratory complication (OR: 1.34; 95% CI: [1.09, 1.64]; p = 0.005), postoperative infection (OR: 1.22; 95% CI [1.07, 1.39]; p = 0.003), and deep vein thrombosis (OR: 1.38; 95% CI: [1.09, 1.74]; p = 0.007).

Conclusions

Our findings suggest that patients with diabetes may be at an increased risk of readmission, infection, respiratory complication, and deep vein thrombosis following shoulder arthroplasty. Shoulder surgeons should consider these potential adverse events when planning postoperative care for patients with diabetes.

Factors Predicting Postoperative Range of Motion and Muscle Strength one Year after Shoulder Arthroplasty

Background

Shoulder arthroplasty improves shoulder range of motion (ROM), strength and function in patients with advanced shoulder disease. However, clinical outcomes vary and are not always predictable among patients. Pre-operative factors and patients' characteristics may influence improvement after surgery. This study examined the impact of the pre-operative objective measures range of motion (ROM) and strength, age, sex, and comorbidities on shoulder ROM, strength status and the amount of improvement one year following shoulder arthroplasty.

Methods

140 patients were assessed pre-operatively and one year after shoulder arthroplasty in this prospective cohort study. Pearson's correlations and multiple regression analyses were performed to test the impact of potential predictors on abduction, flexion, internal rotation and external rotation ROM as well as on shoulder abductors, flexors, internal rotators and external rotators strength at one year.

Results

Pre-operative ROM significantly predicted 10% - 37% of the improvement in ROM after surgery. Less pre-operative ROM was associated with a greater improvement in ROM. Less pre-operative muscle strength was associated with a greater improvement in strength after surgery. Pre-operative shoulder muscles predicted 28% - 38% of the strength status at one year, and 24% - 43% of the improvement in strength postoperatively. Older age was associated with less improvement in ROM and strength at one year. With other predictors, age explained 37% of the change in ROM and 36% of the change in strength. Male sex was associated with greater improvement in muscle strength. Sex significantly predicted 24% - 36% of the change in strength.

Conclusion

Pre-operative ROM and strength, age, and sex are significant predictors of the improvement in the shoulder ROM and strength one year after shoulder arthroplasty. The improvement in these measures is expected to decline with age and men are expected to gain more strength than women following this surgical intervention.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND

Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation.

RESULTS

In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness.

CONCLUSION

We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Effectiveness of surgical and non-surgical interventions for managing diabetic shoulder pain: a systematic review

PURPOSE

This systematic review evaluated and compared the effectiveness of non-surgical and surgical interventions for managing shoulder pain in patients with diabetes.

METHODS

PubMed, Scopus, CINAHL, EMBASE, Sport Discus, and Cochrane library were searched for studies published in the last 20 years. Randomized clinical trials (RCTs) and cohort studies that assessed shoulder pain in patients with diabetes and implemented one or a combination of non-surgical and surgical interventions were eligible for inclusion. The quality of the included studies was assessed using the Structured Effectiveness Quality Evaluation Scale (SEQES) tool. Data extracted from the eligible studies included study design, patient characteristics, duration of symptoms, type of interventions, outcome measures used to assess pain, follow-up intervals, and research findings.

RESULTS

A narrative synthesis with effect sizes (ES) or between-group differences was conducted. A total of 25 (14 non-surgical and 11 surgical) studies met the inclusion criteria. Six studies addressed physiotherapeutic interventions (three RCTs and three cohorts - ES = 0.07-1.3), three studies assessed the effect of steroid injections (two RCTs and one cohort - ES = 0.2-0.4), two cohorts addressed arthrographic capsular distension (between-group difference of 1.1 on Visual Analogue Scale), two cohorts addressed MUA, and one RCT addressed suprascapular nerve block (ES = 1-6). For the surgical studies, six cohorts addressed arthroscopic capsular release (ES = 0.2), three cohorts addressed arthroscopic rotator cuff repair (ES = 0.05-0.5), and one cohort addressed arthroplasty (ES = 0.3).

CONCLUSION

Moderate- to very-low-quality evidence suggests large effects of physiotherapy modalities plus exercise and suprascapular nerve block, and trivial to small effects for surgical interventions for improving shoulder pain in patients with diabetes. Future well-designed studies are needed to provide accurate estimates of the true effects of these interventions on improving shoulder pain in patients with diabetes.Implications For RehabilitationShoulder pain may lead to disability in patients with diabetes.We recommend the use of physiotherapy interventions to reduce shoulder pain.Corticosteroid injections are recommended for short-term shoulder pain relief.

Predictors of Clinical Benefits and One-Year Functional Outcomes Following Shoulder Arthroplasty

BACKGROUND

Shoulder arthroplasty has been shown to improve function in patients with advanced shoulder disease. However, the response to surgery and final outcomes are not easily predictable. This study assessed the effect of residual pain, age, sex, diabetes, hypertension, and depression on changes and status at one-year following arthroplasty with respect to shoulder function and overall physical and mental health status.

METHODS

A retrospective analysis of a prospective cohort of 140 patients tested preoperatively and one-year following shoulder arthroplasty was conducted at our tertiary hospital. Pearson's correlations and multiple regression analysis were performed to test the impact of predictors on shoulder pain and function assessed using the American Shoulder and Elbow Surgery (ASES) questionnaire, and on physical and mental health assessed using the Short Form-12.

RESULTS

Pain and female sex were significant predictors of poorer function at one-year (R = .56, p = .001); and with other predictors, they explained 32% of the variability in function. The explained variability of changes in function scores was 15% with pain being the only significant predictor. Physical health was lower in older patients (r = -.31, p < .05) and was less predictable for physical health change scores (12%) and the physical status at one-year (14%).

CONCLUSIONS

Residual pain is associated with poorer function status and less clinical benefits. Female sex is not associated with less change in function which suggests that men and women get equal benefit from the surgery. Advanced age relates to poorer physical health and to a lesser extent physical change over the year.Level of Evidence: III.