Preoperative patient-reported scores can predict postoperative outcomes after shoulder arthroplasty

Preoperative Mental Health Disorders Affect Opioid Consumption and Perioperative Complications After Total Shoulder Arthroplasty

BACKGROUND

Limited evidence exists regarding the influence of mental health disorders (MHDs) on opioid use and complications after total shoulder arthroplasty (TSA). We aimed to identify the prevalence of common MHDs among patients undergoing anatomic TSA (aTSA) and reverse TSA (rTSA).

MATERIALS AND METHODS

The Premier Healthcare Database was queried for patients undergoing primary aTSA and rTSA from 2016 to 2020. International Classification of Diseases, Tenth Revision, diagnosis codes were used to identify MHDs. Primary outcomes included the prevalence of MHDs, perioperative opioid consumption, and 90-day risk of postoperative complications, revision, and readmission. Bivariate and multivariate regression analyses were performed to assess 90-day risk of primary endpoints while controlling for potential confounders. Statistical significance was defined as P<.05.

RESULTS

From 2016 to 2020, 49,997 of 144,725 (34.55%) patients undergoing primary TSA had at least one diagnosed MHD. The most prevalent were depression (17.03%), anxiety (16.75%), and substance use disorder (10.20%). Patients with a MHD had higher mean hospital costs ($75,984±$43,129 vs $73,316±$39,046, P<.0001), longer mean length of stay (1.95±2.25 days vs 1.61±1.51 days, P<.0001), and higher mean total postoperative opioid use (72.00±231.55 morphine milligram equivalents [MMEs] vs 59.32±127.31 MMEs, P<.0001). Periprosthetic fractures (odds ratio, 1.20; P=.041), dislocation (odds ratio, 1.12; P=.042), and 90-day readmission rates (odds ratio, 1.26; P<.001) were significantly higher among patients with a MHD.

CONCLUSION

This study found that MHDs are associated with significantly increased perioperative opioid consumption, medical and surgical complication rates, and risk of readmission after TSA. Recognition and optimization of MHDs is critical to minimizing complications and opioid consumption after TSA. [Orthopedics. 202x;4x(x):xx-xx.].

Determinants of pain intensity and magnitude of incapability more than two years after arthroscopic Bankart repair for anterior shoulder instability

Background

Individuals treated with arthroscopic Bankart repair after anterior shoulder dislocations experience varied discomfort and incapability. The aim of this study was to determine the relative association of mental health and physical health factors with 1) magnitude of capability and 2) pain intensity 2 or more years after surgery.

Methods

This cross-sectional study evaluated 80 military patients that experienced one or more traumatic anterior shoulder dislocations a minimum of 2 years after arthroscopic Bankart repair without remplissage. We measured capability (Oxford Shoulder Instability Score), pain intensity using an 11-point ordinal scale, symptoms of anxiety (Generalized Anxiety Disorder-2 questionnaire), symptoms of depression (Patient Health Questionnaire-2), catastrophic thinking (Pain Catastrophizing Scale-4), and kinesiophobia (Tampa scale for kinesiophobia-4). We also identified preoperative presence of a Hill-Sachs lesion on radiographs and postoperative occurrence of subluxation or a dislocation episode. A negative binominal regression analysis sought factors associated with magnitude of incapability and pain intensity.

Results

Greater incapability was strongly associated with both greater kinesiophobia (Regression Coefficient [RC] = -0.50; 95% confidence interval [CI] = -0.73 to -0.26; P ≤ .01) and repeat surgery (RC = -0.27; 95% CI = -0.41 to -0.13; P ≤ .01). Greater pain intensity was only strongly associated with greater kinesiophobia (RC = 0.25; 95% CI = 0.039 to 0.46; P = .021).

Conclusion

The observation that greater unhelpful thinking is associated with greater pain intensity and greater magnitude of incapability after a Bankart repair for anterior shoulder instability, whereas pathophysiological factors such as glenoid bone loss were not, emphasizes the degree to which mindset is associated with musculoskeletal health.

Defining minimal clinically important difference, patient acceptable symptomatic state and substantial clinical benefit for the visual analog scale pain score after arthroscopic rotator cuff repair

INTRODUCTION

Patient satisfaction after arthroscopic rotator cuff repair (RCR) is commonly assessed with patient-reported outcome measures (PROMs), and there is an increased need to establish clinical relevance within these measures. The purpose of this study was to (1) define minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for the visual analog scale (VAS) pain score in patients undergoing arthroscopic RCR, and (2) identify preoperative predictors of achieving each of these threshold values.

METHODS

Data from consecutive patients who underwent primary arthroscopic rotator cuff repair study between 2010 and 2016 were prospectively collected. Baseline data and VAS pain scores were collected preoperatively and at 1 year and 2 years postoperatively. MCID, PASS and SCB were determined using an anchor-based approach, with anchor questions assessing postoperative satisfaction and expectation fulfillment. Multivariate logistic regression analysis was also used to identify preoperative predictors for achieving MCID, PASS, and SCB.

RESULTS

A total of 286 patients were included in the final analysis, with an average age of 60.2 ​± ​10.4 and the majority being female (61.2%). The values for the VAS pain score identified to represent MCID, PASS, and SCB, respectively, at 1-year postoperatively were: 5, 2, and 1. The rates of achieving clinically significant improvement based on VAS were 60.5%, 63.3%, and 57.2%, respectively. A higher preoperative VAS was predictive for achieving MCID (odds ratio [OR], 1.84; P ​< ​0.01).

CONCLUSION

This study identified threshold VAS pain scores of 5, 2, and 1 for achieving MCID, PASS, and SCB, respectively, at 1-year follow-up after arthroscopic rotator cuff repair. A higher preoperative VAS pain score was also identified as a statistically significant predictor of attaining MCID after arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

II.

Predictors of poor and excellent outcomes following reverse shoulder arthroplasty for glenohumeral osteoarthritis with an intact rotator cuff

BACKGROUND

As the indications for reverse total shoulder arthroplasty (RSA) continue to evolve, it has been more commonly utilized for the treatment of glenohumeral osteoarthritis with an intact rotator cuff (GHOA). Given the increased use of RSA for GHOA, it is important to identify factors influential of clinical outcomes. In this study, we sought to identify variables predictive of clinical outcomes following RSA for GHOA.

METHODS

Patients undergoing primary RSA for GHOA between 2015 and 2020 were retrospectively identified through a prospectively maintained, single surgeon registry. Eligible patients had complete patient-reported outcome measures and range of motion measurements with a minimum 2-year follow-up. Univariate analysis was utilized to compare characteristics and outcome measures of patients with poor and excellent outcomes, which was defined as postoperative American Shoulder and Elbow Surgeons (ASES) scores in the bottom and top quartiles, respectively. Multivariate linear regression was performed to determine factors independently predictive of postoperative ASES score.

RESULTS

A total of 230 patients were included with a mean follow-up of 33.4 months (SD 13.2). The mean age of the study population was 71.9 (SD 6.1). Two hundred twenty-four patients (97.4%) surpassed the minimal clinically important difference and 209 patients (90.1%) achieved substantial clinical benefit for ASES score. Preoperative factors differing between the poor and excellent outcome groups were sex (male: poor 37.9%, excellent 58.6%; P = .041), opioid use (poor 24.1%, excellent 5.2%; P = .009), ASES score (poor 32.9, excellent 41.0; P = .011), and forward elevation (poor 92°, excellent 101°; P = .030). Linear regression demonstrated that Walch B3 glenoids (β 7.08; P = .010) and higher preoperative ASES scores (β 0.14; P = .025) were predictors of higher postoperative ASES score, while postoperative complications (β -18.66; P < .001) and preoperative opioid use (β -11.88; P < .001) were predictive of lower postoperative ASES scores.

CONCLUSION

Over 90% of patients who underwent RSA for GHOA with an intact rotator cuff experienced substantial clinical benefit. An unsurprising handful of factors were associated with postoperative clinical outcomes; higher preoperative ASES scores were slightly associated with higher postoperative ASES, whereas preoperative opioid use and postoperative complications were associated with lower postoperative ASES. Additionally, Walch glenoid type B3 was associated with higher postoperative ASES, indicating that patients with posterior glenoid defects are not predisposed to poor clinical outcomes following RSA. These results serve as a resource to improve preoperative patient counseling and manage postoperative expectations.

Disease diagnosis and arthroplasty type are strongly associated with short-term postoperative patient-reported outcomes in patients undergoing primary total shoulder arthroplasty

BACKGROUND

Prognostic factors for total shoulder arthroplasty (TSA) clinical outcomes are incompletely understood. This study investigates the associations of preoperative patient, disease-specific, and surgical factors with 1-year postoperative PENN Shoulder Score (PSS) in patients undergoing primary TSA.

METHODS

Cleveland Clinic patients undergoing primary anatomic TSA (aTSA) or reverse TSA (rTSA) for glenohumeral osteoarthritis (GHOA) or rotator cuff tear arthropathy (CTA) between February 2015 and August 2019, and having complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs), were included. Twenty preselected preoperative patient, disease-specific, and surgical factors were used to fit multivariable models for 1-year PSS and its subscores.

RESULTS

Of 1427 eligible primary TSAs, 1174 had 1-year follow-up by PROMs (82%), with 1042 analyzed after additional exclusions, including 30% rTSAs for CTA (n = 308), 26% rTSAs for GHOA (n = 275), and 44% aTSAs for GHOA (n = 459). All PROMs showed statistically significant improvements postoperatively, with 89% of patients reaching an acceptable symptom state. Lower 1-year PSS was associated with younger age, female sex, current smoking, chronic pain diagnosis, history of prior surgery, worker's compensation claim, lower preoperative mental health, lower baseline PSS, absence of glenoid bone loss, and diagnosis-arthroplasty type (CTA-rTSA < GHOA-rTSA < GHOA-aTSA). The most important prognostic factors associated with 1-year PSS were diagnosis-arthroplasty type, baseline mental health status, and insurance status.

CONCLUSIONS

Disease diagnosis, arthroplasty type, and several other baseline factors are strongly and individually associated with PROMs following primary TSA, with patients undergoing aTSA for GHOA demonstrating the highest PROM scores at 1-year follow-up. Patient, disease-specific, and surgical factors can be used to guide postoperative prognosis following primary TSA for improved preoperative patient counseling regarding expected outcomes of these procedures.

Anatomic shoulder arthroplasty: the correlation between patient resilience, mental health, and outcome

BACKGROUND

Recovery from anatomic shoulder arthroplasty may be enhanced in patients with good mental health and the resilience to participate in the prescribed postoperative rehabilitation program. To test this concept, we utilized validated and reliable scales in determining whether resilience and mental health are associated with the outcome of anatomic arthroplasty.

METHODS

Three hundred ninety-nine patients (195 ream and run [RnR] and 204 anatomic total shoulder arthroplasty [aTSA]) were surveyed at a mean follow-up of 6.3 ± 3.3 years. Preoperative variables included age, sex, body mass index, history of prior shoulder surgery, diabetes, visual analog scale for pain, Simple Shoulder Test (SST) scores, and Veteran's RAND 12 Mental Component Score (VR-12 MCS). Outcomes collected included the SST, American Shoulder and Elbow Surgeons (ASES) score, revision rate, and patient satisfaction. Resilience was documented using the Connor-Davidson Resilience Scale 10 (CD-RISC 10) at latest follow-up. Univariable and multivariable regression analyses were used to identify factors significantly associated with follow-up postoperative SST, ASES, and satisfaction.

RESULTS

In the univariable analysis, CD-RISC 10 was positively correlated with postoperative SST, ASES, and satisfaction after both RnR and aTSA. The mean CD-RISC 10 scores were higher in the RnR cohort (34.3 ± 4.8 vs. 32.5 ± 6.2 for aTSA, P < .001). Male sex and lower preoperative visual analog scale for pain were correlated with higher ASES after RnR; VR-12 MCS was positively correlated with all outcomes except SST after RnR. In the multivariable linear regression analysis, CD-RISC 10 was independently associated with postoperative SST, ASES and satisfaction scores in aTSA patients. In the RnR cohort, CD-RISC 10 was only correlated with satisfaction. VR-12 MCS was correlated with ASES and satisfaction after RnR.

DISCUSSION

In this study of anatomic arthroplasties, increased resilience and better mental health were correlated with better outcomes. RnR patients had higher resilience than aTSA patients. Greater resilience was associated with better outcomes after aTSA. Better mental health was associated with superior outcomes after the ream and run procedure.

What are the common factors that lead to the failure to achieve minimal clinically important difference after shoulder surgery? A scoping review

INTRODUCTION

The goal of this research is to identify the factors that negatively impact the achievement of the minimum clinically significant change (MCID) for the American Shoulder and Elbow Surgeons (ASES) score within the realm of various orthopedic shoulder procedures.

METHODS

We conducted a comprehensive review of studies published from 2002 to 2023, utilizing OvidMedline and PubMed databases. Our search criteria included terms such as "minimal clinically important difference" or "MCID" along with associated MeSH terms, in addition to "American shoulder and elbow surgeon" or "ASES." We selectively included primary investigations that assessed factors linked to the failure to achieve MCID for the ASES score subsequent to orthopedic shoulder procedures, while excluding papers addressing anatomical, surgical, or injury-related aspects.

RESULTS

Our analysis identified 149 full-text articles, leading to the inclusion of 12 studies for detailed analysis. The selected studies investigated outcomes following various orthopedic shoulder procedures, encompassing biceps tenodesis, total shoulder arthroplasty, and rotator cuff repair. Notably, factors, such as gender, body mass index, diabetes, smoking habits, opioid usage, depression, anxiety, workers' compensation, occupational satisfaction, and the preoperative ASES score, were all associated with the inability to attain MCID.

CONCLUSION

In summary, numerous factors exert a negative influence on the attainment of MCID following shoulder procedures, and these factors appear to be irrespective of the specific surgical technique employed. Patients presenting with these factors may perceive their surgical outcomes as less successful when compared to those without these factors. Identifying these factors can enable healthcare providers to provide more effective counseling to patients regarding their expected outcomes and rehabilitation course. Furthermore, these findings can aid in the development of a screening tool to better identify these risk factors and optimize them before surgery.

Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

BACKGROUND

Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA.

METHODS

We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA.

RESULTS

Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA.

CONCLUSIONS

Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Variations in 1-year Trajectories of Levels of Pain and Capability After Shoulder Arthroplasty Are Associated With Baseline Mental Health

BACKGROUND

There is variability in the trajectories of pain intensity and magnitude of incapability after shoulder arthroplasty. A better understanding of the degree to which variation in recovery trajectories relates to aspects of mental health can inform the development of comprehensive biopsychosocial care strategies.

QUESTIONS/PURPOSES

(1) Do pain intensities at baseline and the trajectories during recovery differ between groups when stratified by mental health composite summary score, arthroplasty type, and revision surgery? (2) Do magnitudes of capability at baseline and the trajectories during recovery differ between these groups?

METHODS

We used a registry of 755 patients who underwent shoulder arthroplasty by a single surgeon at a specialized urban orthopaedic hospital that recorded the mental component summary (MCS) score of the Veterans RAND 12, a measure of shoulder-specific comfort and capability (American Shoulder and Elbow Surgeons [ASES] score, which ranges from 0 to 100 points, with a score of 0 indicating worse capability and pain and 100 indicating better capability and pain and a minimum clinically important difference of 6.4), and the VAS for pain intensity (range 0 [representing no pain] to 10 [representing the worst pain possible], with a minimum clinically important difference of 1.4) preoperatively, 2 weeks postoperatively, and 6 weeks, 3 months, 6 months, and 1 year after surgery. Forty-nine percent (368 of 755) of the patients were men, with a mean age of 68 ± 8 years, and 77% (585) were treated with reverse total shoulder arthroplasty (rTSA). Unconditional linear and quadratic growth models were generated to identify the general shape of recovery for both outcomes (linear versus quadratic). We then constructed conditional growth models and curves for pain intensity and the magnitude of capability showing mean baseline scores and the rates of recovery that determine the trajectory, accounting for mental health (MCS) quartiles, primary or revision arthroplasty, and TSA or reverse TSA in separate models. Because pain intensity and capability showed quadratic trends, we created trajectories using the square of time.

RESULTS

Patients in the worst two MCS quartiles had greater pain intensity at baseline than patients in the best quartile (difference in baseline for bottom quartile: 0.93 [95% CI 0.72 to 1.1]; p < 0.01; difference in baseline for next-worst quartile: 0.36 [95% CI 0.16 to 0.57]; p < 0.01). The rates of change in recovery from pain intensity were not different among groups (p > 0.10). Patients with revision surgery had greater baseline pain (difference: 1.1 [95% CI 0.7 to 1.5]; p < 0.01) but no difference in rates of recovery (difference: 0.031 [95% CI 0.035 to 0.097]; p = 0.36). There were no differences in baseline pain intensity and rates of recovery between patients with reverse TSA and those with TSA (baseline pain difference: -0.20 [95% CI -0.38 to -0.03]; p = 0.18; difference in rate of recovery: -0.005 [95% CI -0.035 to 0.025]; p = 0.74). Patients in the worst two MCS quartiles had worse baseline capability than patients in the best quartile (difference in baseline for bottom quartile: -8.9 [95% CI -10 to -7.4]; p < 0.001; difference in baseline for the next-worst quartile: -4.9 [95% CI -6.4 to -3.4]; p < 0.01), with no differences in rates of recovery (p > 0.10). Patients with revision surgery had lower baseline capability (difference in baseline: -13 [95% CI -15 to -9.7]; p < 0.01), with a slower rate of recovery (difference in rate of recovery: -0.56 [95% CI -1.0 to -0.079]; p = 0.021). There were no differences in baseline capability or rates of recovery between TSA and reverse TSA.

CONCLUSION

The observation that preoperative and 1-year comfort and capability are associated with mental health factors and with similar recovery trajectories reminds us that assessment and treatment of mental health is best considered an integral aspect of musculoskeletal care. Future studies can address how prioritization of mental health in musculoskeletal care strategies might reduce variation in the 1-year outcomes of discretionary surgeries such as shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Why is female gender associated with poorer clinical outcomes after reverse total shoulder arthroplasty?

INTRODUCTION

There is a lack of gender-specific research after reverse total shoulder arthroplasty (RTSA). Although previous studies have documented worse outcomes in women, a more thorough understanding of why outcomes may differ is needed. We therefore asked: (1) Are there gender-specific differences in preoperative and postoperative clinical scores, complications, surgery-related parameters, and demographics? (2) Is female gender an independent risk factor for poorer clinical outcomes after RTSA? (3) If so, why is female gender associated with poorer outcomes after RTSA?

MATERIALS AND METHODS

Between 2005 and 2019, 987 primary RTSAs were performed in our institution. After exclusion criteria were applied, data of 422 female and 271 male patients were analyzed. Clinical outcomes (absolute/relative Constant Score [a/rCS] and Subjective Shoulder Value [SSV]), complications (intra- and/or postoperative fracture, loosening), surgery-related parameters (indication, implant-related characteristics), and demographics (age, gender, body mass index, and number of previous surgeries) were evaluated. Preoperative and postoperative radiographs were analyzed (critical shoulder angle, deltoid-tuberosity index, reverse shoulder angle, lateralization shoulder angle, and distalization shoulder angle).

RESULTS

Preoperative clinical scores (aCS, rCS, SSV, and pain level) and postoperative clinical outcomes (aCS and rCS) were significantly worse in women. However, the improvement between preoperative and postoperative outcomes was significantly higher in female patients for rCS (P = .037), internal rotation (P < .001), and regarding pain (P < .001). Female patients had a significantly higher number of intraoperative and postoperative fractures (24.9% vs. 11.4%, P < .001). The proportion of female patients with a deltoid-tuberosity index <1.4 was significantly higher than males (P = .01). Female gender was an independent negative predictor for postoperative rCS (P = .047, coefficient -0.084) and pain (P = .017, coefficient -0.574). In addition to female sex per se being a predictive factor of worse outcomes, females were significantly more likely to meet 2 of the 3 most significant predictive factors: (1) significantly worse preoperative clinical scores and (2) higher rate of intra- and/or postoperative fractures.

CONCLUSIONS

Female sex is a very weak, but isolated, negative predictive factor that negatively affects the objective clinical outcome (rCS) after RTSA. However, differences did not reach the minimal clinically important difference, and it is not a predictor for the subjective outcome (SSV). The main reason for the worse outcome in female patients seems to be a combination of higher preoperative disability and higher incidence of fractures. To improve the outcome of women, all measures that contribute to the reduction of perioperative fracture risk should be used.

Sex-related differences in PROMs prior to the outcome: comparison of preoperative PROMIS physical function scores in female vs. male patients undergoing shoulder arthroplasty

Background

Patient-reported outcome measures (PROMs) are increasingly used to evaluate outcomes in patients undergoing shoulder arthroplasty. The Patient-Reported Outcome Measures Information System (PROMIS) is popular due to low cost and question burden. Females have been reported to have lower postoperative PROMIS scores after shoulder surgery, but studies have not focused on a dedicated cohort of shoulder arthroplasty patients or examined upstream differences in preoperative scores. This study aimed to characterize sex differences in baseline PROMIS scores among anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) patients.

Methods

Data were collected over a 9-month period. Demographics, Charlson Comorbidity Index (CCI), smoking status, BMI, American Shoulder and Elbow Surgeons (ASES) scores, PROMIS Pain, Physical Function (PF), Upper Extremity, Depression, and Anxiety scores, as well as Single Assessment Numeric Evaluation (SANE) scores were collected. Student t-tests were performed to determine correlation with baseline PROMs. A minimal clinically important difference (MCID) of 4 was used to determine if a PROMIS score difference between groups was clinically important. Significance was set as P < .05.

Results

A total of 88 females (34 TSAs 54 rTSA) and 99 males (35 TSA, 64 rTSA) were enrolled. Only sex showed a correlation with preoperative PROMIS score. In rTSA patients, females had significantly lower preoperative PROMIS PF scores (P < .05). Among females undergoing TSA vs. rTSA, lower preoperative PROMIS PF scores were found in rTSA (P < .05). These differences exceeded the MCID of 4. The same difference was not found in men undergoing TSA vs. rTSA.

Conclusion

Preoperative sex-based differences in PROMIS scores are underappreciated in the shoulder arthroplasty literature. This is the largest study to date focusing on sex-based differences among a dedicated cohort of TSA and rTSA patients, showing a difference in baseline PROMIS scores between males and females above the MCID. These findings suggest that PROMIS scores are affected by sex-based baseline differences in rTSA patients. Further study should investigate sex-based differences in baseline scores to determine their effects on ultimate outcome.

Clinical Outcomes Following Open Olecranon Bursa Excision for Septic and Aseptic Olecranon Bursitis: An Observational Study

Background and objective Olecranon bursitis (aseptic or septic) is caused by inflammation in the bursal tissue. While it is typically managed with conservative measures, refractory cases may indicate surgical intervention. There is currently limited research about outcomes following bursal excision for both septic and aseptic etiologies. In light of this, the purpose of this study was to determine if patients experienced improvement following surgical olecranon bursa excision and to compare outcomes between septic and aseptic forms. Materials and methods A retrospective review was performed involving patients who underwent olecranon bursa excision from 2014 to 2021. Demographic data, patient characteristics, surgical data, and outcome-related data were collected from the medical records. Patients were classified into subgroups based on the type of olecranon bursitis (septic or aseptic). Preoperative and one-year postoperative 12-item short-form survey (SF-12) results and range of motion (ROM) outcomes were evaluated for the entire cohort as well as the subgroups. Results We included 61 patients in our study and found significant improvement in the Physical Component Scale 12 (PCS-12) score for all patients (42.0 vs. 45.5, p=0.010) following surgery. However, based on subgroup analysis, the aseptic group improved in PCS-12 following surgery (41.5 vs. 46.8, p<0.001), but the septic group did not (43.6 vs. 40.5, p=0.277). No improvements were found in the Mental Component Scale 12 (MCS-12) scores following surgery in either group. Eighteen of the 61 patients experienced postoperative complications (29.5%), but only 6.5% required a second surgical procedure. Specifically, 14 of the 18 complications occurred in the aseptic group while two septic and two aseptic patients required additional surgeries. Elbow ROM did not change significantly after surgery but more patients were found to have full ROM postoperatively (83.0% to 91.8%, p=0.228). Conclusion Our findings suggest that patients with refractory olecranon bursitis, particularly if aseptic, tend to gain significant physical health benefits from open bursectomy.

Outcomes after bilateral shoulder arthroplasty: a systematic review

The purpose of this systematic review was to report outcomes after bilateral shoulder arthroplasty including bilateral total shoulder arthroplasty (TSA), bilateral reverse shoulder arthroplasty (RSA), and ipsilateral TSA with contralateral RSA (TSA/RSA). Two reviewers independently performed a PRISMA-guided systematic search using MEDLINE/PubMed, Embase, and Cochrane Database of Systematic Reviews up to May 11, 2021. The databases were queried using the following search terms: (["bilateral" OR "contralateral"] AND "shoulder" AND ["arthroplast∗" OR "replacement"]). A total of 486 titles/abstracts were screened for eligibility and 19 studies were included in the final analysis. Risk of bias was assessed using Methodological Index for Nonrandomized Studies and Modified Coleman Methodology scores. Analysis compared overall results for bilateral shoulder arthroplasty and sub-group analyses compared TSA (all shoulders from bilateral TSA patients and the TSA shoulder in TSA/RSA patients) to RSA (all shoulders from bilateral RSA patients and the RSA shoulder in TSA/RSA patients), first shoulder arthroplasty to second contralateral shoulder arthroplasty, and interval between arthroplasty (IBA) <20 months to IBA ≥20 months. Nineteen studies analyzed bilateral TSA (n = 3), bilateral RSA (n = 7), and TSA/RSA (n = 8). The mean Methodological Index for Nonrandomized Studies was 18 and mean Modified Coleman Methodology Score was 74, with 63.2% of studies demonstrating level III evidence. A total of 2729 patients (30.4% male; mean age 72.2 years, mean follow-up 47.3 months, mean IBA 20 months) were analyzed. Postoperative forward flexion (142.0° vs. 129.6°), external rotation (ER) (42.5° vs. 25.6°), and internal rotation (60% reaching T12-T8 vs 85.7% reaching L3-L1) were higher for TSA when compared to RSA. Patient reported outcome measures such as Constant-Murley (73.2 vs. 59.2), American Shoulder and Elbow Surgeons (87.9 vs. 77.7), and Single Assessment Numeric Evaluation (SANE) (86.9 vs. 67.8) were higher for TSA when compared to RSA. Patients with IBA ≥20 months demonstrated greater ER and patient satisfaction than patients with IBA <20 months. Postoperative complication rates were 15.1% for TSA and 10.6% for RSA, while reoperation and revision rates were 13.7% for TSA and 7.1% for RSA. Bilateral shoulder arthroplasty results in improvements in motion, strength, pain, function, and high satisfaction. Bilateral TSA is associated with greater improvement in motion and function than bilateral RSA but higher complication, reoperation, and revision rates. IBA ≥20 months is associated with greater ER and satisfaction than IBA <20 months.

Approaching Artificial Intelligence in Orthopaedics: Predictive Analytics and Machine Learning to Prognosticate Arthroscopic Rotator Cuff Surgical Outcomes

Machine learning (ML) has not yet been used to identify factors predictive for post-operative functional outcomes following arthroscopic rotator cuff repair (ARCR). We propose a novel algorithm to predict ARCR outcomes using machine learning. This is a retrospective cohort study from a prospectively collected database. Data were collected from the Surgical Outcome System Global Registry (Arthrex, Naples, FL, USA). Pre-operative and 3-month, 6-month, and 12-month post-operative American Shoulder and Elbow Surgeons (ASES) scores were collected and used to develop a ML model. Pre-operative factors including demography, comorbidities, cuff tear, tissue quality, and fixation implants were fed to the ML model. The algorithm then produced an expected post-operative ASES score for each patient. The ML-produced scores were compared to actual scores using standard test-train machine learning principles. Overall, 631 patients who underwent shoulder arthroscopy from January 2011 to March 2020 met inclusion criteria for final analysis. A substantial number of the test dataset predictions using the XGBoost algorithm were within the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds: 67% of the 12-month post-operative predictions were within MCID, while 84% were within SCB. Pre-operative ASES score, pre-operative pain score, body mass index (BMI), age, and tendon quality were the most important features in predicting patient recovery as identified using Shapley additive explanations (SHAP). In conclusion, the proposed novel machine learning algorithm can use pre-operative factors to predict post-operative ASES scores accurately. This can further supplement pre-operative counselling, planning, and resource allocation. Level of Evidence: III.

Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL.

METHODS

This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups.

RESULTS

Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05).

CONCLUSION

Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores After Reverse Total Shoulder Arthroplasty

INTRODUCTION

Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection.

METHODS

Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition.

RESULTS

A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (β = 0.275, P < 0.001).

CONCLUSION

Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention.

LEVEL OF EVIDENCE

III, diagnostic cohort study.

Preoperative Single Assessment Numeric Evaluation Score Predicts Poor Outcomes After Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears Without Arthritis

Limited clinical evidence is available to help to predict poor outcomes after reverse shoulder arthroplasty (RSA) among patients with massive rotator cuff tears without glenohumeral arthritis. A retrospective case-control study was performed for patients who underwent RSA for massive rotator cuff tear without glenohumeral arthritis (Hamada score ≤3) and had a minimum of 2 years of follow-up. Preoperative risk factors for poor outcomes were subsequently analyzed. Sixty patients (mean age, 71.4±7.4 years) met the inclusion criteria. Of these, 18 (30%) patients had poor outcomes (case group). The case group had significantly worse postoperative Single Assessment Numeric Evaluation (SANE) (61.6±29.5 vs 84.9±14.1, respectively; P=.002), American Shoulder and Elbow Surgeons (58.9±22.5 vs 82.2±14.2, respectively; P<.001), and Simple Shoulder Test (5.4±3.6 vs 8.5±2.4, respectively; P=.002) scores compared with the control group. Patients with poor outcomes had significantly higher preoperative SANE scores compared with control subjects (40.4±28.4 vs 18.8±15.7, respectively; P=.021). The results of this study suggest that patients with better overall preoperative function, as represented by higher SANE scores, have a greater likelihood of poor functional outcomes after RSA for massive rotator cuff tears without glenohumeral arthritis. For these patients, alternative treatment options should be considered. [Orthopedics. 2022;45(4):215-220.].

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction

BACKGROUND

Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown.

METHODS

Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups.

RESULTS

Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts.

CONCLUSION

When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

Substantial Inconsistency and Variability Exists Among Minimum Clinically Important Differences for Shoulder Arthroplasty Outcomes: A Systematic Review

BACKGROUND

As the value of patient-reported outcomes becomes increasingly recognized, minimum clinically important difference (MCID) thresholds have seen greater use in shoulder arthroplasty. However, MCIDs are unique to certain populations, and variation in the modes of calculation in this field may be of concern. With the growing utilization of MCIDs within the field and value-based care models, a detailed appraisal of the appropriateness of MCID use in the literature is necessary and has not been systematically reviewed.

QUESTIONS/PURPOSES

We performed a systematic review of MCID quantification in existing studies on shoulder arthroplasty to answer the following questions: (1) What is the range of values reported for the MCID in commonly used shoulder arthroplasty patient-reported outcome measures (PROMs)? (2) What percentage of studies use previously existing MCIDs versus calculating a new MCID? (3) What techniques for calculating the MCID were used in studies where a new MCID was calculated?

METHODS

The Embase, PubMed, and Ovid/MEDLINE databases were queried from December 2008 through December 2020 for total shoulder arthroplasty and reverse total shoulder arthroplasty articles reporting an MCID value for various PROMs. Two reviewers (DAK, MAM) independently screened articles for eligibility, specifically identifying articles that reported MCID values for PROMs after shoulder arthroplasty, and extracted data for analysis. Each study was classified into two categories: those referencing a previously defined MCID and those using a newly calculated MCID. Methods for determining the MCID for each study and the variability of reported MCIDs for each PROM were recorded. The number of patients, age, gender, BMI, length of follow-up, surgical indications, and surgical type were extracted for each article. Forty-three articles (16,408 patients) with a mean (range) follow-up of 20 months (0.75 to 68) met the inclusion criteria. The median (range) BMI of patients was 29.3 kg/m2 (28.0 to 32.2 kg/m2), and the median (range) age was 68 years (53 to 84). There were 17 unique PROMs with MCID values. Of the 112 MCIDs reported, the most common PROMs with MCIDs were the American Shoulder and Elbow Surgeons (ASES) (23% [26 of 112]), the Simple Shoulder Test (SST) (17% [19 of 112]), and the Constant (15% [17 of 112]).

RESULTS

The ranges of MCID values for each PROM varied widely (ASES: 6.3 to 29.5; SST: 1.4 to 4.0; Constant: -0.3 to 12.8). Fifty-six percent (24 of 43) of studies used previously established MCIDs, with 46% (11 of 24) citing one study. Forty-four percent (19 of 43) of studies established new MCIDs, and the most common technique was anchor-based (37% [7 of 19]), followed by distribution (21% [4 of 19]).

CONCLUSION

There is substantial inconsistency and variability in the quantification and reporting of MCID values in shoulder arthroplasty studies. Many shoulder arthroplasty studies apply previously published MCID values with variable ranges of follow-up rather than calculating population-specific thresholds. The use of previously calculated MCIDs may be acceptable in specific situations; however, investigators should select an anchor-based MCID calculated from a patient population as similar as possible to their own. This practice is preferable to the use of distribution-approach MCID methods. Alternatively, authors may consider using substantial clinical benefit or patient-acceptable symptom state to assess outcomes after shoulder arthroplasty.

CLINICAL RELEVANCE

Although MCIDs may provide a useful effect-size based alternative to the traditional p value, care must be taken to use an MCID that is appropriate for the particular patient population being studied.

Characterization of ASES score pain and functional improvement after anatomic total shoulder arthroplasty: a patient-centered perspective

BACKGROUND

Interpretation of anchor-based clinical differences in the context of pain and functional change remains undefined. The purpose of this study was to characterize American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores for patients after anatomic total shoulder arthroplasty with minimum 1 year of follow-up in terms of pain and change in each functional element on the ASES.

METHODS

We performed a retrospective study of a prospective institutional patient database of primary anatomic total shoulder arthroplasties from 2017-2020 with baseline and 1-year postoperative ASES scores. Three clinical outcome groups were established using an anchor-based global rating of change assessment: minimal clinically important difference (MCID), moderate clinical benefit (MCB), and substantial clinical benefit (SCB). Pain and functional outcomes in each group where then characterized and compared.

RESULTS

A total of 67 patients were analyzed in terms of demographics and clinical outcomes. Two-thirds (65%) of patients achieved the SCB, 24% achieved the MCB, and 10% achieved the MCID. Washing, reaching for a shelf, and throwing were the most common functional deficits experienced preoperatively and accounted for the largest improvement in function postoperatively. Patients in the MCID group had higher preoperative visual analog scale (VAS) pain scores (7.1 ± 3.0) than the MCB (5.8 ± 2.5) or SCB (5.8 ± 2.2) groups (P = .0612). The MCID group had the least amount of preoperative functional deficits when compared to the MCB and SCB groups (P = .041). Postoperative VAS pain scores improved by 5.1 in the SCB, 3.6 in the MCB, and 3.7 in the MCID groups. Functional change in each element of the ASES improved by 1.4/4 in the SCB, followed by 0.9/4 in the MCB group and 0.05/4 in the MCID group (P < .001).

CONCLUSION

The MCID group had higher preoperative pain scores and the least amount of preoperative functional deficits when compared to the MCB and SCB groups. The MCID was realized through pain improvement only, whereas the MCB and SCB consisted of meaningful improvements in pain and function.

No Difference in Clinical Outcomes for Arthroscopic Suprapectoral Versus Open Subpectoral Biceps Tenodesis at Midterm Follow-up: A Randomized Prospective Analysis

BACKGROUND

We have previously reported the 1-year outcomes of arthroscopic suprapectoral biceps tenodesis (ASPBT) versus open subpectoral biceps tenodesis (OSPBT) for the management of long head of the biceps tendon (LHBT) pathology. While patients had similar 1-year biceps muscle strength and pain, longer-term functional outcomes are unknown.

PURPOSE

To directly compare clinical outcomes of ASPBT versus OSPBT with interference screw fixation, distal to the bony bicipital groove, at a minimum of 2 years' follow-up.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 85 patients undergoing biceps tenodesis (BT) for LHBT disease were randomized into the ASPBT or OSPBT group. Both techniques utilized polyether ether ketone inference screws for tenodesis fixation. Patients completed American Shoulder and Elbow Surgeons (ASES), Constant subjective, and Single Assessment Numeric Evaluation (SANE) questionnaires preoperatively and again at 6 months, 12 months, and at the final follow-up at a minimum of 24 months.

RESULTS

A total of 73 patients (37/42 randomized to ASPBT [88%]; 36/42 randomized to OSPBT [86%]) with a mean age of 50.4 ± 10.3 years and a mean body mass index of 29 ± 7.9 were included in clinical outcome analyses. The mean final follow-up was 2.9 years (ASPBT, 3 years; OSPBT, 2.8 years [range 2-5.2 years]). Comparison of demographic characteristics and intraoperative findings showed no significant differences in age, sex, concomitant procedures, and rotator cuff disease. No statistically significant differences in the ASES (P = .25), Constant subjective (P = .52), and SANE scores (P = .61) were found at the final follow-up. Clinical outcomes scores showed no significant improvement from a mean of 12.6 months to the final follow-up at 34.5 months (ASPBT: ASES, P = .43; Constant, P = .25; SANE, P = .45 vs OSPBT: ASES, P = .65; Constant, P = .78; SANE, P = .70). No patients required revision of BT in either group.

CONCLUSION

This study reported a minimum of 2-year follow-up of patients undergoing ASPBT or OSPBT, utilizing the same interference screw technique, for the management of LHBT pathology in the setting of concomitant shoulder procedures. There were no significant differences in patient-reported outcomes and complication rates found at any time point.

REGISTRATION

NCT02192073 (ClinicalTrials.gov identifier).

Predictors of poor and excellent outcomes after reverse total shoulder arthroplasty

BACKGROUND

Favorable clinical and functional outcomes can be achieved with reverse total shoulder arthroplasty (RSA). Given the expanding utilization of RSA in the United States, understanding the factors that influence both excellent and poor outcomes is increasingly important.

METHODS

A single-surgeon prospective registry was used to identify patients who underwent RSA from 2015 to 2018 with a minimum of 2 years' follow-up. An excellent postoperative clinical outcome was defined as a final American Shoulder and Elbow Surgeons (ASES) score in the top quartile of ASES scores. A poor outcome was defined as an ASES score in the bottom quartile. Logistic regression was used to determine preoperative characteristics associated with both excellent and poor outcomes.

RESULTS

A total of 338 patients with a mean age of 71.5 years (standard deviation [SD], 6.4 years) met the inclusion and exclusion criteria. The average preoperative ASES score for the entire cohort was 35.3 (SD, 16.4), which improved to 82.4 (SD, 16.1) postoperatively (P < .001). Univariate analysis demonstrated that a diagnosis of primary osteoarthritis (OA), private insurance, and higher preoperative ASES scores were significantly associated with achieving excellent outcomes (P < .01 for all). Variables predictive of poor outcomes were workers' compensation status (P = .03), depression (P = .02), a preoperative diagnosis of rotator cuff tear arthropathy (P < .01), preoperative opioid use (P < .01), a higher number of allergies (P < .01), and prior ipsilateral shoulder surgery (P < .01). Multivariate regression analysis demonstrated that OA (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.2-26.5; P = .03) and private insurance (OR, 2.7; 95% CI, 1.12-6.5; P = .02) correlated with excellent outcomes whereas a higher number of reported allergies (OR, 0.83; 95% CI, 0.71-0.97; P = .02), self-reported depression (OR, 0.39; 95% CI, 0.16-0.99; P =.04), a history of ipsilateral shoulder surgery (OR, 0.36; 95% CI, 0.15-0.87; P =.02), and preoperative opioid use (OR, 0.26; 95% CI, 0.09-0.76; P = .01) were predictive of poor outcomes.

CONCLUSIONS

A preoperative diagnosis of primary OA is the strongest predictor of excellent clinical outcomes following RSA. Patients with an increasing number of reported allergies, self-reported depression, a history of ipsilateral shoulder surgery, and preoperative opioid use are significantly more likely to achieve poor outcomes after RSA. Given the increasing utilization of RSA, this information is important to appropriately counsel patients regarding postoperative expectations.

Radiographic Severity May Not be Associated with Pain and Function in Glenohumeral Arthritis

BACKGROUND

Despite the routine use of plain radiographs to stratify the severity of glenohumeral osteoarthritis, little is known about the relationship between radiographic measures and patient-perceived pain and function.

QUESTIONS/PURPOSES

(1) What radiographic findings are associated with worse pain and function in patients with glenohumeral osteoarthritis? (2) What demographic factors are associated with worse pain and function in patients with glenohumeral osteoarthritis?

METHODS

This retrospective study included patients presenting for an initial office visit for primary glenohumeral osteoarthritis. Patients with other concurrent shoulder pathologic findings, prior surgery, lack of pain and functional scores, recent injection, or inadequate radiographs were excluded. Between January 2017 and January 2019, 3133 patients were eligible based on these inclusion criteria; 59% (1860) had outcome assessments and 48% (893) of those had radiographs. An additional 42% (378) of those with radiographs were excluded because of other shoulder findings, recent injection, prior surgery, or inadequate radiographs, leaving 16% (515 of 3133) who were fully analyzed in this study. A radiographic review included the joint space width, posterior humeral head subluxation, inferior humeral head osteophyte size, cystic change, and head asphericity. Additionally, radiographic arthritis was classified according to the Walch, Samilson-Prieto, and Kellgren-Lawrence classifications by two separate reviewers. Radiographic and demographic criteria as well as the presence of psychologic or mental illness were correlated with VAS Pain (range 1-10; minimal clinically important difference [MCID] 1.6), American Shoulder and Elbow Surgeons (ASES; range 0-100; MCID 13.6), Single Assessment Numeric Evaluation (SANE; range 0-100; MCID 14), and Simple Shoulder Test (SST; range 0-12; MCID 1.5) scores using univariate and multivariable regression analyses.

RESULTS

After accounting for age, gender, and psychologic illness in the multivariable analysis, we found that patients with Samilson-Prieto Grade 4 arthrosis had lower VAS Pain scores (β = -1.9; p = 0.02) than those with Grade 0 or 1 did; however, no clinically important associations were found between Samilson-Prieto Grade 4 and ASES (β = 7; p = 0.25), SANE (β = 4; p = 0.63), or SST (β = 0.5; p = 0.62) scores. No clinically important associations were found between Kellgren-Lawrence Grade 3 and VAS Pain (β = 1.4; p = 0.10), ASES (β = -8; p = 0.22), SANE (β = -13; p = 0.11), or SST scores (β = 0.4; p = 0.66). Radiographic joint space and posterior subluxation also did not have any clinically important associations with VAS Pain or functional scores. In assessing Walch glenoid type, there was no clinically important association between glenoid type and VAS Pain (F = 3.1; p < 0.01), ASES (F = 1.9; p = 0.15), SANE (F = 0.45; p = 0.66), or SST scores (F = 0.76; p = 0.71). Men had higher SST scores than women did (β = 2.0; p < 0.01), but there were no clinically important differences in VAS Pain (β = -0.4; p = 0.04), ASES (β = 6; p < 0.01), or SANE (β = 4; p = 0.07) scores. No clinically important association was found between age or the presence of any psychologic illness and VAS Pain or functional scores.

CONCLUSION

In patients with glenohumeral arthritis, no consistent clinically important differences in pain or function were discovered with respect to radiographic or demographic factors. Surgeons should understand that the pain levels of patients with glenohumeral arthritis may not parallel radiographic severity. Future studies can build on these findings by examining other non-radiographic or demographic factors that affect pain in patients with shoulder arthritis, such as psychological factors.

LEVEL OF EVIDENCE

Level III, prognostic study.

Why patients fail to achieve a Patient Acceptable Symptom State (PASS) after total shoulder arthroplasty?

Background

The purpose of this study was to compare patient-reported outcomes (PROs) and range of motion (ROM) measurements between patients achieving and failing to achieve a Patient Acceptable Symptom State (PASS) after anatomic total shoulder arthroplasty (TSA) to determine which PRO questions and ROM measurements were the primary drivers of poor outcomes.

Methods

A retrospective review of a multicenter database identified 301 patients who had undergone primary TSA between 2015 and 2018 with ROM and PRO data recorded preoperatively and at a minimum of two years postoperatively. The primary outcome was the difference in active ROM between patients achieving and failing to achieve the PASS threshold for the American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. The secondary outcome was the difference in self-reported pain levels between those achieving and failing to achieve a PASS.

Results

Based on the ASES PASS threshold, 87% (261/301) of patients achieved a PASS after TSA, whereas 13% did not. Based on the SANE PASS threshold, 69% (208/301) of patients achieved a PASS after TSA, whereas 31% did not. Patients who failed to achieve a PASS after TSA were younger and had lower short form-12 mental health scores than those who did. There was a significant difference in pain between those who achieved and failed to achieve a PASS after TSA (ASES PASS current shoulder pain 16.5% vs. 95%, P < .001, SANE PASS current shoulder pain 13% vs. 58.1%, P < .001). Those failing to reach a PASS had significantly higher pain levels (ASES PASS Visual Analog Scale pain scores [4.2 vs. 0.4, P < .001] and SANE PASS Visual Analog Scale pain scores [2.0 vs. 0.4, P < .001]) and worse function in nearly all domains of the ASES and Western Ontario Osteoarthritis of the Shoulder index after surgery. There was little difference in ROM between those reaching and failing to reach a PASS (no difference in active external rotation with the arm adducted, active internal rotation at the nearest spinal level, or active internal rotation with the shoulder abducted to 90 degrees for ASES and SANE PASS).

Conclusion

There is variability in the percentage of patients who achieve a PASS after TSA, ranging from 69% to 87% depending on the PRO used to define the threshold. Patients who did not achieve a PASS after TSA were significantly more likely to have pain, whereas there were very few differences in ROM, indicating pain as the primary driver of failing to achieve a PASS. Setting realistic postoperative expectations for pain relief may be important for improving patient-reported results after TSA.

Patients undergoing anatomic total shoulder arthroplasty achieve clinically significant outcomes faster than those undergoing reverse shoulder arthroplasty

BACKGROUND

Clinically significant outcome (CSO) benchmarks have been previously established for outcome assessment after total shoulder arthroplasty. However, the time required to achieve CSO improvement is not well understood. The purpose of this study was to (1) determine the time-dependent achievement of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) in patients undergoing either anatomic total shoulder (TSA) or reverse total shoulder arthroplasty (RTSA) and compare the results of the 2 populations and (2) identify variables associated with earlier or delayed achievement of each CSO.

METHODS

A prospectively maintained institutional registry was retrospectively queried for all patients receiving a primary TSA or RTSA between September 2, 2016-October 31, 2017. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was administered to all patients preoperatively and at standardized postoperative time periods: 5-7 months (6-month time point), 11-13 months (1-year time point), and 23-25 months (2-year time point). Cumulative percentages of CSO achievement were calculated using Kaplan-Meier survival curve analysis with interval censoring. A Weibull parametric survival regression analysis was used to investigate the influence of demographic and clinical variables on delayed or earlier CSO achievement.

RESULTS

A total of 153 patients (157 shoulders) undergoing TSA (n = 76) and RTSA (n = 81) were included in the study population. The RTSA cohort was older (70.2 ± 7.5 vs. 61.0 ± 8.4, P < .001), had a lower BMI (28.8 ± 5.9 vs. 31.5 ± 6.5, P = .006), and a greater proportion of females (53.1% vs. 32.9%, P = .017) relative to TSA. For SCB, there was a significant difference in the cumulative percentage of TSA and RTSA patients reaching this threshold at both the 6-month (77.3% vs. 59.0%, P = .024) and 2-year (92.0% vs. 79.5%, P = .048) time periods, with similar findings demonstrated for PASS. There was a significant difference in the average time required to achieve the PASS (TSA: 6.1 months vs. rTSA: 11.6 months, P = .009), but not the MCID (P = .407) or SCB (P = .153). Factors significantly associated with earlier achievement of more than 1 of the CSO benchmarks were regular preoperative physical exercise and diagnosis of rotator cuff tear without osteoarthritis.

CONCLUSION

Patients undergoing RTSA had lower rates of achieving SCB and PASS at both 6 months and 2 years compared to patients undergoing TSA. Patients undergoing RTSA on average required nearly double the time to achieve PASS compared with those undergoing TSA. In both groups, clinically significant improvement continued for the entire 2-year duration of study follow-up.

Preoperative ASES Scores Can Predict Substantial Clinical Benefit at 2 Years Following Total Shoulder Arthroplasty

Preoperative patient-reported outcome measures (PROMs) have been shown to influence outcomes after total shoulder arthroplasty (TSA), although little is known about this relationship. An institutional shoulder arthroplasty registry was retrospectively queried for preoperative and 2-year postoperative 12-Item Short Form Health Survey (SF-12) and American Shoulder and Elbow Surgeons (ASES) scores for patients who underwent anatomic TSA (aTSA) or reverse TSA (rTSA). Preoperative PROMs were evaluated for their effect on patient achievement of minimal clinically important improvement (MCII) and substantial clinical benefit (SCB). In total, 451 aTSA patients and 93 rTSA patients had preoperative and 2-year follow-up scores. A total of 91.7% and 70.4% of patients achieved MCII and SCB at 2 years, respectively (P<.001). Preoperative ASES scores were more predictive of achieving SCB than MCII (area under the curve [AUC], 0.83 vs 0.71). When accounting for mental and emotional health, the predictive ability of SF-12 physical component threshold values improved (AUC, 0.68). Preoperative threshold PROMs were found to accurately predict achievement of clinically significant outcomes at 2 years. Considering mental and emotional health improved the accuracy of these predictions. These data will assist surgeons and patients alike in setting expectations for outcomes after TSA. [Orthopedics. 2021;44(4):e509-e514.].

Preoperative factors associated with loss of range of motion after reverse shoulder arthroplasty

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) is a successful procedure, often allowing patients to achieve better range of motion (ROM) compared with their preoperative baseline. However, there is a subset of patients who either fail to improve or lose ROM postoperatively. These patients are at increased risk of poor satisfaction and patient-reported outcomes. To date, characteristics of this subset of patients have not been well described. The purpose of this study is to determine risk factors associated with loss of ROM after primary RTSA.

METHODS

A retrospective review using a commercial international RTSA database (Exactech Inc., Gainesville, FL, USA) of patients who underwent primary RTSA between 2007 and 2017 was performed. A total of 123 (7.7%) shoulders lost ≥10° of forward elevation (FE) (group 1, P₁) and 183 (11.4%) lost ≥10° of external rotation (ER) (group 2, P₂). Univariate and multivariate analyses were performed comparing these patients with control cohorts to evaluate risk factors for loss of motion.

RESULTS

Better preoperative abduction, FE, ER, and internal rotation were each associated with greater loss of FE (P₁ < .001) and ER (P₂ < .001) postoperatively. Higher preoperative Simple Shoulder Test (P₁ < .001, P₂ < .001), Constant (P₁ < .001, P₂ < .001), Shoulder Pain and Disability Index (P₁ < .001, P₂ < .001), American Shoulder Elbow Surgeons (P₁ < .001), and University of California at Los Angeles (P₁ < .001) scores were also strongly associated with loss of ROM postoperatively. Other factors associated with a higher risk of losing ROM included a diagnosis of irreparable rotator cuff tear (P₁ = .038), rotator cuff arthropathy (P₁ = .017, P₂ ≤ .001), and inflammatory arthropathy (P₁ = .021). After multivariate analysis, higher preoperative FE (P₁ < .001), internal rotation (P₁ = -.018), and weight (P₁ = .008) remained significant predictors of loss of FE. Better preoperative FE (P₂ = .003), ER (P₂ < .001), and University of California at Los Angeles score (P₂ < .001) remained significant predictors of loss of ER. Patients who lost FE or ER were more likely to report lower satisfaction scores than their counterparts who did not lose ROM (P₁ < .001, P₂ < .001).

CONCLUSION

Patients with greater preoperative shoulder ROM or higher patient-reported outcomes are at higher risk of losing ROM after primary RTSA. They are also at higher risk of reporting lower postoperative satisfaction, though the majority were still satisfied. Surgeons should strongly counsel patients with well-preserved preoperative function on the risk of loss of ROM.

Defining recovery trajectories after shoulder arthroplasty: a latent class analysis of patient-reported outcomes

BACKGROUND

Patients undergoing total shoulder arthroplasty (TSA) can have varying levels of improvement after surgery. As patients typically demonstrate a nonlinear recovery trajectory, advanced analysis investigating the degrees of variation in outcomes is needed. Latent class analysis (LCA) is a mixed and multilevel model that estimates random slope variance to evaluate heterogeneity in outcome patterns among patient subgroups and can be used to outline differing recovery trajectories. The purpose of this study was to determine recovery trajectory patterns after TSA and to identify factors that predict a given trajectory.

METHODS

Data from a prospectively collected single institutional database of patients undergoing anatomic and reverse TSA were utilized. Patients were included if they had American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores preoperatively, as well as postoperative scores at 6 weeks, 6 months, 1 year, and 2 years. Patients were excluded if they underwent a revision procedure or hemiarthroplasty or had prior infection. LCA was used to subdivide the patient cohort into subclasses based on postoperative recovery trajectory. This was performed for all patients as well as anatomic TSA and reverse TSA as separate groups. Unpaired Student t tests, analysis of variance, and Fisher exact test were used to compare classes based on factors including age, body mass index, sex, preoperative diagnosis, and type of arthroplasty.

RESULTS

A total of 244 TSAs were included in the final analysis, comprising 89 anatomic TSA and 155 reverse TSA. In the combined group, LCA modeling revealed 3 patterns for recovery: Resistant Responders had low baseline scores (ASES < 30) and poor final results (ASES < 50), Steady Progressors had moderate baseline scores (ASES 30-50) with moderate final results (ASES 50-75), and High Performers had moderate baseline scores (ASES > 50) with excellent final results (ASES > 75). For anatomic TSA, we identified Delayed Responders with moderate baseline scores and a delayed response before ultimately achieving moderate final results, Steady Progressors with moderate baseline scores and a steady progression to achieve moderate final results, and High Performers who had moderate baseline scores and excellent final results. For reverse TSA, we identified Late Regressors with low baseline scores and poor final results, Steady Progressors with moderate baseline scores and moderate final results, and High Performers with moderate baseline scores and excellent final results.

CONCLUSIONS

Patients recover in a heterogenous manner following TSA. Through LCA, we identified different recovery trajectories for patients undergoing anatomic TSA and reverse TSA.

Equal care for all? Do surgical outcomes in shoulder arthroplasty depend on insurance type?

BACKGROUND

Although it has been shown that Medicare populations have a higher overall rate of complications than those with private insurances for large cohort total joint studies, there is limited information comparing patient-reported outcomes (PROs) among private insurance patients. The purpose of this study was to determine the impact of non-Medicaid insurance type on outcomes after shoulder arthroplasty.

METHODS

This retrospective case-controlled study included 203 patients who underwent shoulder arthroplasty from 2012 to 2017 by a single surgeon. Preoperative and postoperative PROs were collected and included the Simple Shoulder Test, the American Shoulder and Elbow Surgeons Shoulder Assessment Form, and the Constant Shoulder Score. Patients were categorized into groups based on insurer-preferred provider organization, health maintenance organization, Medicare, and Veterans Affairs Care program-and outcomes were compared between groups.

RESULTS

The 4 insurance provider groups were matched for body mass index, surgery type, and comorbidities (P = .526). Preoperatively, no significant differences in PROs between groups were present except for the Constant Shoulder Score (P = .029). All payer groups significantly improved from preoperative to postoperative PROs (P ≤ .001). At the final follow-up, no significant difference in PROs between groups were seen (American Shoulder and Elbow Surgeons Shoulder mean 75.3 ± 20.9 [P = .757], Simple Shoulder Test of 9.1 ± 2.9 [P = .312], and Constant Shoulder Score of 65.0 ± 15.2 [P = .526]).

CONCLUSIONS

Our results suggest variations in insurance type did not significantly impact outcomes for our cohort of patients undergoing shoulder arthroplasty. Although variations in patient cohorts exist, patients regardless of insurance type and coverage variations can expect significant improvements in their function and pain after shoulder arthroplasty.

Relationship Between Glenoid Component Shift and Osteolysis After Anatomic Total Shoulder Arthroplasty: Three-Dimensional Computed Tomography Analysis

BACKGROUND

The purpose of this study was to evaluate glenoid component position and radiolucency following anatomic total shoulder arthroplasty (TSA) using sequential 3-dimensional computed tomography (3D CT) analysis.

METHODS

In a series of 152 patients (42 Walch A1, 16 A2, 7 B1, 49 B2, 29 B3, 3 C1, 3 C2, and 3 D glenoids) undergoing anatomic TSA with a polyethylene glenoid component, sequential 3D CT analysis was performed preoperatively (CT1), early postoperatively (CT2), and at a minimum 2-year follow-up (CT3). Glenoid component shift was defined as a change in component version or inclination of ≥3° from CT2 to CT3. Glenoid component central anchor peg osteolysis (CPO) was assessed at CT3. Factors associated with glenoid component shift and CPO were evaluated.

RESULTS

Glenoid component shift occurred from CT2 to CT3 in 78 (51%) of the 152 patients. CPO was seen at CT3 in 19 (13%) of the 152 patients, including 15 (19%) of the 78 with component shift. Walch B2 glenoids with a standard component and glenoids with higher preoperative retroversion were associated with a higher rate of shift, but not of CPO. B3 glenoids with an augmented component and glenoids with greater preoperative joint-line medialization were associated with CPO, but not with shift. More glenoid component joint-line medialization from CT2 to CT3 was associated with higher rates of shift and CPO. A greater absolute change in glenoid component inclination from CT2 to CT3 and a combined absolute glenoid component version and inclination change from CT2 to CT3 were associated with CPO. Neither glenoid component shift nor CPO was associated with worse clinical outcomes.

CONCLUSIONS

Postoperative 3D CT analysis demonstrated that glenoid component shift commonly occurs following anatomic TSA, with increased inclination the most common direction. Most (81%) of the patients with glenoid component shift did not develop CPO. Longer follow-up is needed to determine the relationships of glenoid component shift and CPO with loosening over time.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Health-related quality-of-life improvement after hallux valgus corrective surgery

BACKGROUND

Hallux valgus is a common forefoot deformity that affects function of foot and quality of life (QoL). This study aims to identify factors associated with clinically important improvements in QoL after hallux valgus corrective surgery.

METHODS

A retrospective analysis on 591 cases of hallux valgus corrective surgery performed between 2007 and 2013 was conducted. Patients' preoperative and 2-year postoperative Physical Component Score (PCS) and Mental Component Score (MCS) were compared to identify the presence of clinically significant improvements in patient-reported QoL. A multiple logistic regression model was developed through a stepwise variable-selection model building approach. Age, BMI, preoperative patient reported outcome score, PCS, MCS, pain score, gender, side of surgery, type of surgery, and presence of lesser toe deformities or metatarsalgia were considered.

RESULTS

Median PCS significantly improved from 49 to 53 (p < 0.001), and median MCS remained at 56 (p = 0.724). Age, preoperative MCS and PCS were independent predictors for significant improvements of PCS at 2-year postoperatively.

CONCLUSION

Three groups of patients were more likely to have significant QoL improvements after hallux valgus corrective surgery. These were the younger patients, those with better preoperative mental health or those with poorer preoperative physical health.

LEVEL OF EVIDENCE

III.

Minimal Clinically Important Difference in Robotic-Assisted Total Knee Arthroplasty Versus Standard Manual Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to determine whether robotic total knee arthroplasty (R-TKA) demonstrated evidence of improvement in minimal clinically important difference (MCID) in early (<4 weeks) and intermittent (4-8 month) patient-reported outcomes compared with manual total knee arthroplasty (M-TKA).

METHODS

A prospectively collected database was reviewed of 1160 consecutive patients undergoing R-TKA or M-TKA from December 2017 to October 2019. Primary outcomes consisted of Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and Patient-Reported Outcomes Measurement Information System Global Health Measures of Physical Health (PH) and Mental Health (MH). Statistical analysis included MCID via the distribution method.

RESULTS

Univariate analysis demonstrated conflicting results for early MCID achievement favoring M-TKA (4-week KOOS-JR, P = .03) for the multisurgeon cohort, but favored R-TKA (4-week Patient-Reported Outcomes Measurement Information System-PH, P = .04) in the single-surgeon analysis, and the remaining outcome scores were similar. Ultimately, multivariate analysis demonstrated similar 4-week and 6-month MCID achievement in all measures. Lower preoperative scores consistently achieved MCID at a higher rate in M-TKA, although in R-TKA, the higher baseline scores improved at a rate comparable with those with lower scores in all but the short-term postoperative KOOS-JR.

CONCLUSION

R-TKA demonstrated comparable MCID achievement to M-TKA across the larger cohort. Single-surgeon comparison did show some early benefit. Confounding variables such as surgical technique, implant fixation, and responsiveness of an outcome measure may be as important as simply what tools are used during surgery. Such granular data should be sought out in future studies.

Development of supervised machine learning algorithms for prediction of satisfaction at 2 years following total shoulder arthroplasty

BACKGROUND

Patient satisfaction after primary anatomic and reverse total shoulder arthroplasty (TSA) represents an important metric for gauging patients' perception of their care and surgical outcomes. Although TSA confers improvement in pain and function for most patients, inevitably some will remain unsatisfied postoperatively. The purpose of this study was to (1) train supervised machine learning (SML) algorithms to predict satisfaction after TSA and (2) develop a clinical tool for individualized assessment of patient-specific risk factors.

METHODS

We performed a retrospective review of primary anatomic and reverse TSA patients between January 2014 and February 2018. A total of 16 demographic, clinical, and patient-reported outcomes were evaluated for predictive value. Five SML algorithms underwent 3 iterations of 10-fold cross-validation on a training set (80% of cohort). Assessment by discrimination, calibration, Brier score, and decision-curve analysis was performed on an independent testing set (remaining 20% of cohort). Global and local model behaviors were evaluated with global variable importance plots and local interpretable model-agnostic explanations, respectively.

RESULTS

The study cohort consisted of 413 patients, of whom 331 (82.6%) were satisfied at 2 years postoperatively. The support vector machine model demonstrated the best relative performance on the independent testing set not used for model training (concordance statistic, 0.80; calibration intercept, 0.20; calibration slope, 2.32; Brier score, 0.11). The most important factors for predicting satisfaction were baseline Single Assessment Numeric Evaluation score, exercise and activity, workers' compensation status, diagnosis, symptom duration prior to surgery, body mass index, age, smoking status, anatomic vs. reverse TSA, and diabetes. The support vector machine algorithm was incorporated into an open-access digital application for patient-level explanations of risk and predictions, available at https://orthopedics.shinyapps.io/SatisfactionTSA/.

CONCLUSION

The best-performing SML model demonstrated excellent discrimination and adequate calibration for predicting satisfaction following TSA and was used to create an open-access, clinical decision-making tool. However, rigorous external validation in different geographic locations and patient populations is essential prior to assessment of clinical utility. Given that this tool is based on partially modifiable risk factors, it may enhance shared decision making and allow for periods of targeted preoperative health-optimization efforts.

Preoperative Expectations of Patients Undergoing Knee Surgery

There is limited validated data regarding the relationship between preoperative expectations and patient-reported outcomes (PROs) in patients undergoing knee surgery. The purpose of this study was to (1) assess the preoperative expectations of patients undergoing knee surgery and (2) determine the relationship between preoperative patient demographics, PROs, and preoperative patient expectations. We hypothesized that younger patients with worse function and worse general health status would have greater expectations of knee surgery. We analyzed data from 399 patients undergoing knee surgery at an urban academic medical center. We utilized the Musculoskeletal Outcomes Data Evaluation and Management System to measure preoperative expectations. Multiple legacy PRO measures were recorded, as well as the new Patient-Reported Outcomes Measurement Information Systems (PROMIS) Computer Adaptive Testing. Nonparametric statistical analyses were performed to determine significance. Overall, patients undergoing knee surgery had high expectations, with a mean of 88.0 (95% confidence interval [CI], 86.7-89.3) and median of 91.7 (95% CI, 89.2-94.3). Greater preoperative expectations of knee surgery were associated with higher income, surgically naïve knee, lower Charlson Comorbidity Index, better PROMIS Depression and Anxiety scores, greater Marx knee activity scores, and lower total body pain (p < 0.05). Preoperative expectations of patients undergoing knee surgery are associated with a history of prior knee surgery, income, general and mental health, activity, and pain. Expectations were also found to be associated with PRO measures of function and psychological well-being. These findings may have implications for patient education and shared decision-making preoperatively. The level of evidence for the study is IV.

Patient-Reported Outcomes Measurement Information System Scores Are Inconsistently Correlated With Legacy Patient-Reported Outcome Measures in Shoulder Pathology: A Systematic Review

PURPOSE

To evaluate the current literature regarding Patient-Reported Outcomes Measurement Information System (PROMIS) and its correlation to legacy patient-reported outcomes measures (PROMs) in 5 domains: (1) rotator cuff disease, (2) shoulder instability, (3) shoulder arthroplasty, (4) proximal humerus fractures, and (5) glenohumeral arthritis. The secondary purpose is to evaluate the floor and ceiling effects, the number of questions, and time needed to complete PROMIS and legacy PROMs in shoulder care.

METHODS

A systematic review of the available literature on PROMIS scores in shoulder care was performed. This review was accomplished per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies that reported data on 1485 patients met inclusion criteria. There was a strong correlation between general function PROMs and the PROMIS PF for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and proximal humerus fractures. In addition, there was a strong correlation between PROMIS UE and legacy PROMs in patients with rotator cuff injury and shoulder instability. PROMIS instruments asked fewer questions than legacy PROMs (9.46 vs 12.99, respectively), took less time to complete (88.21 vs 96.53 seconds, respectively), had less floor effects in both PROMIS PF and UE (0.17% and 0.62% vs 2.89%, respectively), and had lower ceiling effects for PROMIS PF but not PROMIS UE assessments (0.17% and 6.37% vs 1.89%, respectively).

CONCLUSIONS

This systematic review demonstrated PROMIS instruments have varying correlations with legacy PROMs measures for patients with rotator cuff disease, shoulder instability, shoulder arthroplasty, and glenohumeral arthritis. PROMIS instruments do measure clinical outcomes faster and with fewer questions. Other than PROMIS UE v1.2 ceiling effects, PROMIS instruments have lower rates of floor and ceiling effects.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Surgical Intervention for Femoroacetabular Impingement Can Lead to Improvements in Both Hip and Back Function in Patients With Coexisting Chronic Back Pain at 1-Year Follow-Up

PURPOSE

To determine whether patients with coexisting lumbar back pain experience back pain improvement after undergoing hip arthroscopy for femoroacetabular impingement (FAI).

METHODS

An institutional review board-approved retrospective chart review compared patients undergoing hip arthroscopy for FAI with lumbar spine back pain to patients solely reporting hip pain. The modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) were recorded preoperatively and at 1-year follow up. The Oswestry Disability Index score, which quantifies disability from lower back pain, and visual analog scale were recorded from the hip-spine cohort alone. Statistical analysis was performed using paired sample t tests with P ≤ .05 considered significant.

RESULTS

Sixty-eight patients who underwent hip arthroscopy between November 2016 and October 2018 were enrolled. Thirty-four patients with a mean age of 48.2 ± 14.0 years and body mass index of 26.6 ± 6.6 had a history of back pain and 34 patients were age- and sex-matched for the matched-control (MC) cohort. The MC cohort had lower mHHS and NAHS scores preoperatively. The MC cohort reported a larger increase in the mHHS (P = .01) and NAHS scores (P = .01) postoperatively. More patients in the MC cohort reached minimally clinically important difference with mHHS (P = .003) and NAHS (P = .06). Following surgery, the hip-spine cohort reported a lower Oswestry Disability Index score, indicating minimal disability (P = .01).

CONCLUSIONS

Surgical intervention for FAI can lead to improvements in hip and back pain in patients with coexisting lumbar pathology.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Sex Differences in Clinical Outcomes Following Surgical Treatment of Femoroacetabular Impingement

BACKGROUND

Sex-based differences in clinical outcomes following surgical treatment of femoroacetabular impingement remain largely uncharacterized; this prospective, multicenter study evaluated these differences both directly and adjusted for covariates.

METHODS

Hips undergoing surgical treatment of symptomatic femoroacetabular impingement were prospectively enrolled in a multicenter cohort. Patient demographics, radiographic parameters, intraoperatively assessed disease severity, and history of surgical procedures, as well as patient-reported outcome measures, were collected preoperatively and at a mean follow-up of 4.3 years. A total of 621 (81.6%) of 761 enrolled hips met the minimum 1 year of follow-up and were included in the analysis; 56.7% of analyzed hips were female. Univariate and multivariable statistics were utilized to assess the direct and adjusted differences in outcomes, respectively.

RESULTS

Male hips had greater body mass index and larger α angles. Female hips had significantly lower preoperative and postoperative scores across most patient-reported outcome measures, but also had greater improvement from preoperatively to postoperatively. The preoperative differences between sexes exceeded the threshold for the minimal clinically important difference of the modified Harris hip score (mHHS) and all Hip disability and Osteoarthritis Outcome Score (HOOS) domains except quality of life. Preoperative sex differences in mHHS, all HOOS domains, and Short Form-12 Health Survey physical function component score were greater than the postoperative differences. A greater proportion of female hips achieved the minimal clinically important difference for the mHHS, but male hips were more likely to meet the patient acceptable symptom state for this outcome. After adjusting for relevant covariates with use of multiple regression analysis, sex was not identified as an independent predictor of any outcome. Preoperative patient-reported outcome scores were a strong and highly significant predictor of all outcomes.

CONCLUSIONS

Significant differences in clinical outcomes were observed between sexes in a large cohort of hips undergoing surgical treatment of femoroacetabular impingement. Despite female hips exhibiting lower baseline scores, sex was not an independent predictor of outcome or reoperation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reverse total shoulder arthroplasty for patients with minimal preoperative pain: a matched-cohort analysis

BACKGROUND

Profound improvements in function have been described in patients following reverse total shoulder arthroplasty (RSA). Previous studies have demonstrated young age, high preoperative function, and neurologic dysfunction to be predictors of poor functional improvement. However, no study to date has focused on patients electing to undergo RSA for function more than pain. The purpose of this study was to compare the outcomes of RSA in patients with minimal preoperative pain with those in patients who have higher baseline pain.

METHODS

We performed a retrospective matched-cohort study of RSA patients treated by a single surgeon with a minimum of 2 years' follow-up. Patients with at least moderate baseline pain (function-pain group), predefined by existing literature as a visual analog scale pain score > 3, were matched 3:1 based on sex, indication, and age to patients with minimal pain (function group), defined as a visual analog scale score ≤ 3. Patient-reported outcome measures, active range of motion, and overall satisfaction were compared. The percentage of maximal improvement in outcomes and the proportion of patients exceeding the established threshold that predicts excellent satisfaction were also compared.

RESULTS

A total of 260 patients (195 in function-pain group and 65 in function group) were selected for matched analysis with a similar sex distribution; the mean age was 73.1 years, and the mean follow-up period was 50 months. No differences in most recent postoperative function, overall improvement in functional scores, and active motion were found between patients in the 2 groups (P > .05). However, pain scores improved only in patients with at least moderate baseline pain (P < .0001). Patient satisfaction was significantly different (P = .035), as 10.8% of patients who elected to undergo RSA for function were unsatisfied. The function cohort also had worse percentage of maximal Simple Shoulder Test score (P = .034) and American Shoulder and Elbow Surgeons score (P < .0001) improvement, and a lower proportion of these patients exceeded the threshold for the percentage of maximal improvement that predicts an "excellent" outcome (P < .0001).

CONCLUSION

RSA patients with minimal preoperative pain achieve significant improvements in function and motion similar to those who choose to undergo RSA for both pain and function, but they are less satisfied and are less likely to achieve an excellent outcome. Patients electing to proceed with RSA with minimal pain should be counseled accordingly.

How can we define clinically important improvement in pain scores after biceps tenodesis?

BACKGROUND

Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.

PURPOSE

To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point.

METHODS

Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.

RESULTS

A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms >6 months was predictive of a reduced likelihood to achieve PASS.

CONCLUSION

This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptom State of Outcome Measures Relating to Shoulder Pathology and Surgery: a Systematic Review

PURPOSE OF THE REVIEW

To provide a comprehensive summary of available literature on the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) of patient-reported outcome measures (PROMs) for various shoulder conditions and outcomes and to identify factors that influence these metrics.

RECENT FINDINGS

Over the past 2 years, there has been an increasing interest in utilizing MCID, SCB, and PASS as a gauge to evaluate the success of an intervention for shoulder conditions. Efforts at calculating these thresholds have yielded multiple and inconsistent values and are further compounded by the proliferation of different PROMs in the shoulder literature. The MCID, SCB, and PASS values of shoulder PROMs vary widely with study-specific characteristics, including patient demographics, shoulder pathology, treatment, shoulder instrument, study methodology, and calculation method. The differences in these factors are not inconsequential and could lead to large discrepancies in threshold values. It is crucial that clinicians are mindful of these variables when designing future studies to calculate these metrics or when utilizing previously published values to determine the success of an intervention.

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them.

PURPOSE

To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs.

RESULTS

A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; P = .014) achieved CSOs earlier on ASES, while patients with workers' compensation status (HR, 0.752; 95% CI, 0.592-0.955; P = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; P = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; P = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; P = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, P = .004) achieved CSOs earlier on Constant, while patients with workers' compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; P = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; P < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; P = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; P < .001).

CONCLUSION

A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers' compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.

Are Oxford Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index Useful Predictors of Clinical Meaningful Improvement and Satisfaction After Total Hip Arthroplasty?

BACKGROUND

Up to 15% of patients express dissatisfaction after total hip arthroplasty (THA). Preoperative patient-report outcome measures (PROMs) scores can potentially mitigate this by predicting postoperative satisfaction, identifying patients that will benefit most from surgery. The aim of this study was to (1) calculate the minimal clinically important difference (MCID) thresholds for Oxford Hip Score (OHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) mental component summary (MCS) and physical component summary (PCS) scores and (2) identify the threshold values of these PROMs that could be used to predict patient satisfaction and expectation fulfilment.

METHODS

Prospectively collected registry data of 1334 primary THA patients who returned for 2-year follow-up from 1998 to 2016 were reviewed. All patients were assessed preoperatively and postoperatively at 2 years using the OHS, WOMAC, and SF-36 PCS/MCS scores. The MCID for each PROMs was calculated, and the proportion of patients that attained MCID was recorded. The relationship between satisfaction, expectation fulfilment, and MCID attainment was analyzed using Spearman rank correlation. Optimal threshold scores for each PROM that predicted MCID attainment and satisfaction/expectation fulfilment at 2 years were calculated using receiver operating curve analysis.

RESULTS

The calculated MCID for OHS, WOMAC, SF-36 PCS, and SF-36 MCS were 5.2, 10.8, 6.7, and 6.2, respectively. A threshold value of 24.5 for the preoperative OHS was predictive of achieving WOMAC MCID at 2 years after THA (area under the curve 0.80, P < .001). 93.1% of patients were satisfied, and 95.5% had expectations fulfilled at 2 years. None of the PROMs were able to predict satisfaction.

CONCLUSION

OHS and WOMAC scores can be used to determine clinical meaningful improvement but are limited in their ability to predict patient satisfaction after THA.

Comparative Outcomes of Various Combinations of Bilateral Shoulder Arthroplasty

Background: In the setting of bilateral shoulder arthroplasty (BSA), differences in functional outcomes and motion between anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are unknown. The purpose of this study was to compare the effectiveness of treatment for various combinations of TSA procedures. Methods: A review of prospectively collected data from an institutional shoulder surgery repository was performed for patients who underwent any combination of bilateral TSA or RSA surgery. Based on the combination of shoulder arthroplasty, patients were divided into the following subgroups: bilateral TSA (TSA/TSA), bilateral RSA (RSA/RSA), or unilateral TSA with contralateral RSA (TSA/RSA). A total of 73 patients (146 shoulders), with a minimum of 2-year follow-up, who underwent any combination of bilateral TSA or RSA from 2007 to 2014 were included. Pre- and postoperative patient-reported outcome measures and measured motion were evaluated between the 3 groups. Results: There were 47 TSA/TSA, 17 RSA/RSA, and 9 TSA/RSA patients with a mean age of 72 years and mean follow-up of 51 months. Preoperatively, TSA/TSA had significantly higher Simple Shoulder Test scores, Visual Analog Scale (VAS) function, active elevation, and active external rotation compared with RSA/RSA. Postoperative scores were significantly superior in TSA/TSA compared with other combinations of shoulder arthroplasty except VAS pain and function. Change in pre- to postoperative (effectiveness of treatment) internal rotation was superior in the TSA/TSA group compared with RSA/RSA and TSA/RSA; however, no other differences were observed. Conclusions: Bilateral TSA patients have higher preoperative function and motion. Although some postoperative outcomes differ among combinations of BSA, the overall effectiveness of treatment for patients undergoing BSA is similar between various combinations of arthroplasty.

Validation of a Mobile Version of the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form: An Observational Randomized Crossover Trial

Background

The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) questionnaire is an effective tool for evaluating shoulder joint function. The development and usage of a mobile version of the ASES questionnaire has the potential to save time, money, and effort.

Objective

The aim of this study is to assess the equivalence between the paper and mobile versions of the ASES questionnaire and their acceptability among patients.

Methods

The paper and mobile versions of the ASES questionnaire were used to evaluate the shoulder joint function of 50 patients with shoulder pain. This study included patients from the shoulder clinic of Sun Yat-sen Memorial Hospital. The intraclass correlation coefficient (ICC) and Bland-Altman method were used to evaluate the agreement (reliability) of the scores obtained by the two methods (paper versus mobile).

Results

Of the 50 patients recruited from March 2018 to May 2019, 46 (92%) completed the study. There was a high agreement between the paper and mobile versions of the ASES questionnaire (ICC=0.979, 95% CI 0.943-0.987; P<.001). The mean difference between the scores of the mobile and paper versions was 1.0, and only 1/46 (2%) had a difference greater than the minimal clinically important difference of 12 points. About 75% of patients preferred the mobile version to the paper version.

Conclusions

Our study shows that the mobile version of the ASES questionnaire is comparable to the paper version, and has a higher patient preference. This could prove to be a useful tool for epidemiological studies and patient follow-up over longer periods of time.

Of Major Complication Types, Only Deep Infections After Spinal Fusion Are Associated With Worse Health-related Outcomes in Children With Cerebral Palsy

STUDY DESIGN

Retrospective review.

OBJECTIVE

The aim of this study was to determine whether major postoperative complications ("complications") are associated with 2-year improvements in Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) scores after scoliosis surgery, and whether complications and preoperative characteristics predict 2-year improvements in CPCHILD Total score.

SUMMARY OF BACKGROUND DATA

Spinal arthrodesis can halt the progression of spinal deformity in patients with cerebral palsy (CP)-related scoliosis. However, these patients are prone to postoperative complications.

METHODS

Using a multicenter CP registry, we identified 222 patients aged ≤21 years who underwent spinal fusion from 2008 to 2015 and had ≥2-year follow-up. We compared CPCHILD score improvement between 71 patients who had 1 or more complications ("complications group") versus 151 who did not ("no-complications group"). Complications were deep infections, thromboembolic events, and cardiopulmonary, gastrointestinal, and neurologic complications. Multiple linear regression was used to identify predictors of 2-year postoperative CPCHILD score improvement (alpha = 0.05).

RESULTS

At 2-year follow-up, the complications group had similar mean improvement in CPCHILD score across all domains compared with the no-complications group (P > 0.05). When stratifying by complication type, deep infection was associated with less improvement in CPCHILD Comfort and Emotions (P = 0.02), Quality of Life (P < 0.01), and Total (P = 0.04) scores. When controlling for Gross Motor Function Classification System subcategory, age, and body mass index, only preoperative CPCHILD Total score and postoperative deep infection (F[4, 176] = 14; P < 0.0001; R = 0.24) predicted 2-year improvement in CPCHILD Total score. Higher preoperative Total score and postoperative deep infection independently predicted less improvement in Total score.

CONCLUSION

Postoperative deep infection and higher preoperative CPCHILD Total score independently predicted less improvement in CPCHILD Total score. Other major postoperative complications were not associated with differences in 2-year postoperative improvements in CPCHILD scores across all domains.

LEVEL OF EVIDENCE

3.

Minimal clinically important differences after subpectoral biceps tenodesis: definition and retrospective assessment of predictive factors

BACKGROUND

Minimal clinically important differences (MCIDs) at 1 year after subpectoral biceps tenodesis are unknown for the American Shoulder and Elbow Surgeons (ASES) scale, Subjective Shoulder Value (SSV), and visual analog scale (VAS) for pain. Our objectives were to determine MCIDs for these measures at 1 year after biceps tenodesis and to identify preoperative factors that predict attainment of MCIDs.

METHODS

We included 52 patients who underwent arthroscopic débridement, decompression, and mini-open biceps tenodesis from 2016-2018. We analyzed age, sex, body mass index value, arm dominance, diagnosis, range of shoulder motion, and preoperative and 1-year postoperative ASES, SSV, and VAS scores. MCIDs were calculated using a distribution-based method of one-half the standard deviation. Preoperative thresholds predictive of MCIDs were calculated with univariate logistic regression. Multiple logistic regression was used to determine factors that predict MCIDs. Significance was set at a 2-tailed P value of <.05.

RESULTS

MCIDs for the ASES, SSV, and VAS were 13, 12, and 1.6 points, respectively. Preoperative ASES score <59 predicted MCID on the ASES (P = .03); VAS score >3 predicted MCID on the VAS (P < .01); external shoulder rotation >40° predicted MCID on the SSV (P = .02); and age >41 years predicted MCID on the VAS (P = .02).

CONCLUSION

At 1 year after débridement, decompression, and biceps tenodesis, MCIDs were 13, 12, and 1.6 points for the ASES, SSV, and VAS, respectively. Patients most likely to attain MCIDs were those aged >41 years, those with the most preoperative pain, and those with the poorest preoperative shoulder function.

Patient-Reported Outcome Measures and Health-Related Quality-of-Life Scores of Patients Undergoing Anatomic Total Shoulder Arthroplasty

BACKGROUND

Health-related quality-of-life (HRQoL) scores are required for cost-effectiveness and health-care value analysis. We evaluated HRQoL scores and patient-reported outcome measures (PROMs) in patients with advanced glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty to establish values of HRQoL scores that can be used for cost-effectiveness and value analysis and to assess relationships between HRQoL scores and shoulder and upper-extremity PROMs.

METHODS

We analyzed 143 patients (143 shoulders) with glenohumeral osteoarthritis treated with anatomic total shoulder arthroplasty; 92 patients had 1-year follow-up. Preoperative and postoperative functional outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) for shoulder pain and function. Health utility was assessed with the EuroQol-5 Dimensions (EQ-5D), Short Form-6 Dimensions (SF-6D), and VAS Quality of Life (VAS QoL). HRQoL score validity was determined through correlations between the PROMs and HRQoL scores. The responsiveness of HRQoL scores was measured through the effect size and the standardized response mean.

RESULTS

There were significant improvements in all PROMs and HRQoL scores (p < 0.001) at 1 year after the surgical procedure. The changes in VAS QoL (very weak to moderate), EQ-5D (weak), and SF-6D (weak) were significantly correlated (p < 0.05) with the changes in PROMs, demonstrating comparably acceptable validity. There were large effect sizes in the VAS QoL (1.843), EQ-5D (1.186), and SF-6D (1.084) and large standardized response mean values in the VAS QoL (1.622), EQ-5D (1.230), and SF-6D (1.083), demonstrating responsiveness. The effect sizes of all PROMs were larger than those of the HRQoL scores.

CONCLUSIONS

PROMs and HRQoL scores are not interchangeable, and studies of the cost-effectiveness and value of shoulder arthroplasty should incorporate both shoulder and upper-extremity PROMs and HRQoL scores. The findings of this study provide data on HRQoL scores that are specific to the treatment of advanced glenohumeral osteoarthritis with anatomic total shoulder arthroplasty and can be used for future cost-effectiveness and value analysis studies.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of preoperative pain in patients undergoing shoulder surgery using the PROMIS pain interference computer-adaptive test

OBJECTIVE

The purpose of this study was to evaluate the Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive testing Pain Interference (PROMIS PI) item bank in patients undergoing shoulder surgery. We hypothesized that PROMIS PI would exhibit a strong positive correlation with the numerical pain scale for the operative shoulder (shoulder NPS) with less floor and ceiling effects. Secondary study aims included assessing the relationships between patient characteristics and PROMIS PI.

DESIGN

Analytical cross-sectional study.

SETTING

Urban academic medical center.

PATIENTS

One-hundred and ninety-five patients undergoing shoulder surgery between June 2015 to June 2017.

MAIN OUTCOME MEASURES

All patients completed a series of patient-reported outcomes measures, including PROMIS PI and NPS. Non-parametric tests were used for bivariate analysis. Multivariable regression models were used to determine independent associations.

RESULTS

There was a moderate correlation between the PROMIS PI and shoulder NPS scores (r_s = 0.53; p < 0.001). PROMIS PI had no ceiling or floor effects while shoulder NPS had 26 patients (13.3%) at either the floor or the ceiling. PROMIS PI demonstrated a strong correlation with PROMIS Physical Function (r_s = -0.65; p < 0.001), ASES total score (r_s = -0.67; p < 0.001), and PROMIS Fatigue (r_s = 0.64; p < 0.001).

CONCLUSIONS

The strong association noted between PROMIS PI and psychosocial and behavioral factors, versus that of NPS, demonstrates that PROMIS Pain Interference may be a more appropriate choice as an outcome measure where the surgeon is concerned about a patient's improvement of functioning and decrease in the impact of pain in other aspects of wellbeing following shoulder surgery.

LEVEL OF EVIDENCE

IV.

Predicting the need for surgical intervention prior to first encounter for individuals with shoulder complaints: a unique approach

Background

Increasing demand for musculoskeletal care necessitates efficient scheduling and matching of patients with the appropriate provider. However, up to 47% to 60% of orthopedic visits are made without formal triage. The purpose of this study was to develop a method to identify, prior to the initial office visit, the probability that a patient with shoulder symptoms will need surgery so that he or she can be appropriately matched with an operative or nonoperative provider. We hypothesized that patients who had an injury, previously saw an orthopedic provider, or previously underwent magnetic resonance imaging on the affected shoulder would be more likely to undergo surgery.

Methods

Drawing from expert opinion on potential risk factors (which could be identified prior to the initial office visit) for requiring operative intervention for a chief complaint of shoulder symptoms, we developed a branching-logic questionnaire that required a maximum of 7 responses from the patient during the scheduling process. We administered the questionnaire to patients calling with a chief complaint of shoulder symptoms at the time of initial appointment scheduling in a sports health network. A chart review was later completed to determine the ultimate treatment (operative vs. nonoperative) of each patient's complaint. A multivariate predictive model was then developed to determine the characteristics of patients with a higher surgical risk.

Results

We successfully developed a model capable of determining surgical risk from 7% to 90% based on patient sex, previous magnetic resonance imaging status, and injury status.

Conclusions

Our predictive model can aid in patient clinical scheduling and ensure optimal matching of a patient with the best provider for the patient's care. Decreased wait times and appropriate matching may lead to increased patient satisfaction, superior outcomes, and more efficient use of health care resources.