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

Investigating the Role of Symptom Duration and Critical Shoulder Angle in Predicting Acromiohumeral Interval Reversibility in Patients With Massive Rotator Cuff Tears

Background

Acromiohumeral interval (AHI) reversibility is used to evaluate whether superior humeral migration is fixed or flexible in patients with massive rotator cuff tears (MRCTs). AHI reversibility is measured as the difference in the AHI observed between standard and stress radiography. However, factors affecting AHI reversibility have not been studied in the existing literature.

Purpose

To investigate potential factors affecting AHI reversibility in patients with MRCTs.

Study Design

Case-control study; Level of evidence, 3.

Methods

A retrospective analysis was conducted on 58 patients with MRCTs, who had undergone magnetic resonance imaging, computed tomography, and stress radiography of the same shoulder. Potential factors affecting AHI reversibility were evaluated by stepwise regression analysis.

Results

A total of 58 patients (26 male, 32 female) were included in this study. The mean age of the patients was 66.4 ± 8.3 years. There were 33 patients classified as having a reversible AHI and 25 patients classified as having an irreversible AHI. Age, time from symptom onset, anteroposterior tear size, critical shoulder angle (CSA), acromial index, and subscapularis Goutallier grade were associated with AHI reversibility in univariate analysis. Multivariate linear regression analysis showed that a longer time from symptom onset and a bigger CSA were significantly associated with lower AHI reversibility. No significant association was found between AHI reversibility and sex; body mass index; activity level; tear retraction; biceps condition; deltoid cross-sectional area; and Goutallier grade of the supraspinatus, infraspinatus, and teres minor muscles. The cutoff values to predict AHI reversibility for time from symptom onset and CSA were found to be 5.5 years and 38°, respectively.

Conclusion

Time from symptom onset (>5.5 years) and CSA (>38°) were significant independent factors of AHI reversibility. These factors should be considered for the decision-making process in patients with MRCTs.

Clinical outcomes validate the RAND/UCLA appropriateness criteria algorithm for anatomical total shoulder arthroplasty for streamlining the clinical decision-making process

Aims

A recent study used the RAND Corporation at University of California, Los Angeles (RAND/UCLA) method to develop anatomical total shoulder arthroplasty (aTSA) appropriateness criteria. The purpose of our study was to determine how patient-reported outcome measures (PROMs) vary based on appropriateness.

Methods

Clinical data from a multicentre database identified patients who underwent primary aTSA from November 2004 to January 2023. A total of 390 patients (mean follow-up 48.1 months (SD 42.0)) were included: 97 (24.9%) were classified as appropriate, 218 (55.9%) inconclusive, and 75 (19.2%) inappropriate. Patients were classified as "appropriate", "inconclusive", or "inappropriate", using a modified version of an appropriateness algorithm, which accounted for age, rotator cuff status, mobility, symptomatology, and Walch classification. Multiple pre- and postoperative scores were analyzed using Pearson's chi-squared test and one-way analysis of variance (ANOVA). Postoperative complications were also analyzed.

Results

All groups achieved significant improvement in mean PROM scores postoperatively. "Appropriate" patients experienced significantly greater improvement in visual analogue scale (VAS) and American Shoulder and Elbow Surgeons (ASES) score compared to "inconclusive" and "inappropriate". The appropriate group had a significantly greater proportion of patients who achieved minimal clinically important difference (MCID) (95.8%; n = 93) and substantial clinical benefit (SCB) (92.6%; n = 89). Overall, 13 patients had postoperative complications. No significant differences in postoperative complications among classifications were found.

Conclusion

Our data clinically validate the RAND/UCLA aTSA appropriateness criteria algorithm, allowing for more rapid and reliable determination of aTSA candidacy. "Appropriate" patients were more likely to achieve MCID and SCB for ASES scores compared to "inappropriate" patients. Among "appropriate" patients who did not achieve SCB, 50% (n = 4) had a postoperative complication. There was a significantly higher proportion of postoperative complications among those who did not achieve SCB across all three groups. Only 7.1% (n = 1) of patients who did not achieve SCB in the inappropriate group had a postoperative complication. Thus, it can be inferred that the failure to reach SCB in the appropriate group was likely to be due to a postoperative complication, whereas for patients deemed "inappropriate", failure to reach SCB may be secondary to factors accounted for within our algorithm.

Associations of mental, social, and pathophysiological factors with pain intensity and capability in patients with shoulder osteoarthritis prior to shoulder arthroplasty: a Dutch Arthroplasty Register Study

BACKGROUND

Mounting evidence suggests that mental health accounts for greater variation in levels of comfort and capability than pathophysiology severity across a range of musculoskeletal conditions. Using nationwide Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies) data, we tested the null hypothesis that none of the available mental, social, and pathophysiological factors are associated with variation in levels of comfort and capability among people with shoulder osteoarthritis (OA) prior to arthroplasty.

METHODS

We included all adult patients who underwent primary total shoulder arthroplasty for OA in the period 2014-2021 with complete measures of shoulder specific capability (Oxford Shoulder Score), pain intensity (10-point Numeric Rating Scale), general wellbeing (the EQ-5D 3-L), the grade of pathophysiology (Walch classification) and categorized social health based on a social deprivation index. In total, 1342 patients with shoulder OA preparing for shoulder arthroplasty were included in a regression analysis to seek factors associated with variation in levels of pain intensity and capability.

RESULTS

Greater pain intensity at rest was associated with greater symptoms of anxiety and depression (regression coefficient [RC] = -0.41; 95% confidence interval [CI] = 0.17-0.64; P < .01) and women (RC = 0.38; 95% CI = 0.11-0.66; P < .01). Greater incapability was associated with greater symptoms of anxiety and depression (RC = -3.2; 95% CI = -4.0 to -2.4; P < .01), an American Society of Anesthesiologists score of III and IV (RC = -3.1; 95% CI = -4.8 to -1.4; P < .01), older age (RC = -0.098; 95% CI = -0.15 to -0.047; P <. 01), and women (RC = -3.9; 95% CI = -4.9 to -3.0; P < .01). Neither comfort nor capability were associated with Walch classification or social deprivation index.

CONCLUSION

The confirmation that variation in levels of comfort and capability among people preparing for shoulder arthroplasty are associated with mindset rather than a measure of glenoid pathophysiology points to the potential benefits of addressing mental health in musculoskeletal health strategies.

A validated algorithm using current literature to judge the appropriateness of anatomic total shoulder arthroplasty utilizing the RAND/UCLA appropriateness method

BACKGROUND

Currently, appropriateness criteria evaluating when to perform total shoulder arthroplasty (TSA) is lacking. In the absence of society guidelines and limited quality evidence, the RAND/University California in Los Angeles (UCLA) method provides a suitable alternative to evaluate appropriateness and assist in clinical decision making. Given the rise in utilization, appropriateness criteria for TSA have the potential to be an extremely powerful tool for improving quality of care and controlling costs. Thus, the goal of this study was to test explicit criteria to assess the appropriateness of TSA decision making using the RAND/UCLA appropriateness method.

METHODS

A review of recent scientific literature to gather available evidence about the use, effectiveness, efficiency, and the risks involved in surgical intervention was performed by a shoulder/elbow fellowship trained physician. Based on pertinent variables including age, rotator cuff status, previous surgical management, mobility, symptomatology, and imaging classifications, 186 clinical scenarios were created. Appropriateness criteria for TSA were developed using a modified Delphi method with a panel consisting of American Shoulder and Elbow Surgeons (ASES) members. A second panel of ASES members rated the same scenarios, with reliability testing performed to compare groups.

RESULTS

Panel members reached agreement in 40 (64%) indications. TSA was appropriate in 15 (24%) of indications. For patients with severe symptomatology, TSA was often appropriate for patients aged <75 years and inconclusive or inappropriate for patients aged >75 years. Among patients aged <65 years, TSA varied between appropriate and inconclusive, often dependent on Walch classification. For patients with moderate symptomatology, TSA was inappropriate or inconclusive for patients aged <65 or >75 years. When compared to the second panel's results, moderate agreement was obtained with a weighted kappa statistic of 0.56.

CONCLUSIONS

Using the RAND/UCLA method, ASES members created an appropriateness decision tree for pertinent patient variables. This presents the data in a manner that streamlines the clinical decision-making process and allows for rapid and more reliable determination of appropriateness for practitioners. The decision tree is based on a combination of clinical experience from high-volume ASES-member surgeons and a comprehensive review of current evidence. This tool can be used as part of a broader set of factors, including individual patient characteristics, prior studies, and expert opinion, to inform clinical decision making, improve quality of care, and control costs.