PROMIS CAT forms demonstrate responsiveness in patients following reverse shoulder arthroplasty across numerous health domains

BackgroundTo better optimize the administration and postoperative tracking of patients using PROM, the Patient-Reported Outcomes Measurement Information System (PROMIS) was established by the National Institutes of Health. PROMIS CAT domains have been since validated in multiple orthopedic interventions of the shoulder. However, no one to date has studied the responsiveness of PROMIS CAT domains in a cohort of patients undergoing reverse shoulder arthroplasty. The purpose of this study was to investigate the responsiveness of three PROMIS CAT domains in patients undergoing reverse shoulder arthroplasty.MethodsPatients undergoing reverse shoulder arthroplasty by a board-certified shoulder and elbow surgeon were included in this study. PROMIS CAT Upper Extremity Physical Function (“PROMIS-UE”), Pain Interference (“PROMIS-PI”), and Depression (“PROMIS-D”) scores were collected preoperatively and at five postoperative timepoints. Patient-centric demographic factors, range of motion, and clinical characteristics were also reviewed and analyzed for association with PROMIS scores.Results104 patients undergoing primary reverse shoulder arthroplasty were included in this study. The patient cohort consisted of 52 males (50%), with an average age of 70.3 years (standard deviation, 11.2), and a BMI of 30.2 (standard deviation, 6.1). All three PROMIS domains showed significant improvement as early as 6 weeks after surgery, with values of 32.4 ± 6.6, 56.2 ± 7.5, and 44.6 ± 8.6, for PROMIS-UE, PROMIS-PI, and PROMIS-D, respectively. Significant improvements were noted for each postoperative timepoint thereafter, with 1-year follow-up values as follows: 42.1 ± 8.7, 52.5 ± 8.6, and 43.6 ± 9.5 for PROMIS-UE, PROMIS-PI, and PROMIS-D, respectively. Moderate correlations were identified with postoperative PROMIS-UE and abduction (r = 0.439, p < 0.01), as well as postoperative PROMIS-PI and PROMIS-D (r = 0.502, p < 0.01).ConclusionsPROMIS CAT forms demonstrate responsiveness in patients undergoing reverse shoulder arthroplasty.Level of EvidenceLevel II; Retrospective Study     

Changes in Patient Reported Outcome Measure Scores From Initial Presentation to Day-of-Surgery in Patients Undergoing Hip and Knee Arthroplasty

BackgroundIt is not well understood how patient reported outcome measures (PROMs) change from initial presentation to day-of-surgery (DOS). This study sought to quantify preoperative PROM changes for hip and knee arthroplasty patients.MethodsA retrospective review was performed on primary total hip, total knee, and partial knee arthroplasty patients from October 2020 through January 2021. Trends in preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores were compared using scores at initial presentation in the ambulatory clinic and at a time near the date-of-surgery. A total of 497 patients possessed 2 preoperative PROMIS-PF (497/497), HOOS-JR (152/497), or KOOS-JR (258/497) surveys.ResultsThere was no significant statistical difference in mean PROM scores between initial presentation and DOS PROMIS-PF or HOOS-JR scores. Only KOOS-JR demonstrated a significant statistical difference of 2 ± 14 (P = .002) when comparing initial versus preoperative scores. Partial knee arthroplasty patients saw a strong positive correlation (r = 0.77) between initial PROMIS-PF and DOS scores. However, mean absolute value changes on an individual level were 4 ± 4, 11 ± 39, and 11 ± 10 for PROMIS-PF, HOOS-JR, and KOOS-JR, respectively, indicating the presence of meaningful patient-level score changes as based on previously published anchor-based minimal clinically important differences.ConclusionPROMs collected during the preoperative period demonstrated wide variability at an individual level, but not at a population level. Collection at both time points may be necessary in order to understand the clinical impact of surgery on these patients.     

Characterizing MCID and assessing the role of preoperative PROMIS scores in predicting outcomes for reverse total shoulder arthroplasty at 2-year follow-up

BackgroundThe Patient-Reported Outcomes Measurement Information System (PROMIS) has gained more ground as a reliable and efficient means of collecting patient outcomes in different shoulder surgeries. The purpose of this study is to determine if preoperative PROMIS scores are able to predict improvement in postoperative PROMIS scores and anchor this data to determine if a patient will achieve MCID after reverse total shoulder arthroplasty (RTSA). We hypothesize that preoperative PROMIS will significantly correlate, with anchor questions allowing clinicians to predict which patients are most likely to achieve MCID after RTSA.MethodsThree PROMIS CAT forms (PROMIS Upper Extremity Physical Function CAT v2.0 (“PROMIS-UE”), PROMIS Pain Interference v1.1 (“PROMIS-PI”), and PROMIS Depression v1.0 (“PROMIS-D”)) were provided to all patients scheduled to undergo RTSA by board-certified shoulder and elbow surgeons at 1 institution. Demographic data was collected, including age, median household income, zip code, body mass index, sex, smoking status, and race. All patients enrolled in the study were contacted and asked the same 3 anchor questions pertaining to the 3 PROMIS CAT forms above.ResultsA total of 71 patients (52.1% male) were included in our cohort with an average age of 67.8 years (standard deviation, 8.4). Mean follow-up time point was 21.4 months (standard deviation, 9.9) after surgery. Neither preoperative PROMIS-UE, nor preoperative PROMIS-PI showed any significant predictive ability to achieve their respective domain MCIDs (AUC: 0.564 and 0.631, respectively). PROMIS-UE and PROMIS-PI improved to a significant degree at an average 21.4 months postoperatively from 29.2 ± 5.8 and 63.8 ± 4.8 to 39.8.9 ± 8.9 and 50.0 ± 9.7, respectively. Improvements in PRMOIS-D scores were insignificant at average 21.4 months (Baseline: 49.8 ± 8.0 vs. 44.5 ± 9.4 at final follow-up). Using anchor-based analysis to determine MCID, we found the following MCID values for PROMIS-UE, PROMIS-PI, and PROMIS-D: 7.0, -6.6, and -3.9, respectively. ROC analysis revealed MCID values for PROMIS-UE, PI, and D as 7.0, -6.6, and -3.9 respectively (AUC: 0.743, 0.805, 0.601). SCB values for PROMIS-UE, PI, and D were identified as 8.4, -12.1, and -4.0, respectively (AUC: 0.883, 0.932, 0.652).ConclusionsPROMIS-UE and PROMIS-PI questionnaires can adequately assess the symptoms and outcomes of RTSA patients out to two years postoperatively. Preoperative baseline PROMIS-UE, PROMIS-PI, and PROMIS-D scores cannot adequately predict achievement of MCID in patients indicated for primary RTSA when using anchor-based methods at final follow-up, and should not be used to counsel patients on surgery or guide postoperative treatment.Level of EvidenceLevel II; Retrospective Cohort Study     

Is there a threshold of preoperative function that predicts failure to achieve clinically significant outcomes after total and reverse shoulder arthroplasty?

BackgroundThe purpose of this study was to determine if there is a threshold of preoperative function that is predictive of postoperative outcomes and the likelihood of achieving clinically significant outcomes following shoulder arthroplasty (SA).MethodsWe retrospectively identified patients who underwent a primary SA at our institution. Patients with preoperative and postoperative American Shoulder and Elbow Surgeons scores (ASES) were included in our analysis. A receiver operating characteristic (ROC) analysis was utilized to reach a preoperative ASES threshold correlated with achievement of the following clinically significant outcomes: minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state. This analysis was performed for our entire SA cohort and subanalyzed for total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). Fischer exact tests were used to analyze categorical data while continuous data were analyzed using t-tests. For the ROC, area under the curve (AUC) was calculated, along with bootstrap 95% confidence intervals and P values, with <0.05 as significant.ResultsA total of 516 patients were included (164 TSA and 352 RSA). ROC analysis yielded a preoperative ASES above 54 as predictive of failure to achieve MCID for all SAs (AUC, 0.77; P < .001), above 49 for TSA (AUC 0.74, P < .001), and above 56 for RSA (AUC 0.79, P < .001). Patients with preoperative ASES scores above 54 were significantly less likely to achieve MCID (odds ratio 5.1, P < .001) and SCB (odds ratio 7.2, P < .001); however, they had higher postoperative ASES scores (84 vs. 78, P < .001). A preoperative ASES score of 73 corresponded to a 50% chance of achieving MCID. ROC analysis also yielded a preoperative ASES score above 51 as predictive of failure to achieve SCB for all SA, TSA, and RSA (AUC: 0.79, 0.78, and 0.80, respectively, all P < .001). A preop ASES score of 52 corresponded to a 50% chance of achieving SCB.ConclusionPreoperative ASES scores above 49-56 are predictive of failure to achieve MCID and SCB following TSA and RSA. Although patients above these preoperative thresholds achieve higher absolute ASES scores at the final follow-up, they experienced less relative improvement from baseline. This will help surgeons counsel individual patients about appropriate expectations after arthroplasty.     

Role of preoperative PROMIS scores in predicting postoperative outcomes and likelihood of achieving MCID following reverse shoulder arthroplasty

BackgroundThe patient-reported outcomes measurement information system (PROMIS) has emerged as an efficient and valid outcome measure in various shoulder surgeries. The purpose of this study was to investigate the influence of preoperative PROMIS scores in predicting postoperative PROMIS scores and the likelihood of achieving a minimal clinically important difference (MCID) following primary reverse total shoulder arthroplasty for cuff tear arthropathy. We hypothesize that preoperative PROMIS scores will influence both postoperative PROMIS scores and the probability of achieving MCID.Methods73 patients undergoing reverse shoulder arthroplasty by a board-certified shoulder and elbow surgeon were given three PROMIS CAT forms: PROMIS Upper Extremity Physical Function CAT v2.0 (“PROMIS-UE”), PROMIS Pain Interference v1.1 (“PROMIS-PI”), and PROMIS Depression v1.0 (“PROMIS-D”).). PROMIS CAT domain t scores were assessed for significance between both time points using a Paired Samples t test. Minimal clinically important difference (MCID) was calculated using the distribution method and each PROMIS domain was subsequently assessed for its discriminatory ability in predicting postoperative improvement equal to or greater than the MCID through receiver operating characteristic (ROC) curve analysis.ResultsOur cohort consisted of 73 patients (49.3% male) and an average age of 69.7 years (standard deviation, 11.9). Mean follow-up time point was 9.6 months (standard deviation, 5.0) after surgery. Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D were 29.5 ± 6.2, 63.3 ± 5.4, and 50.1 ± 9.2, respectively. Each domain significantly improved at 10-months, on average, to 40.9 ± 7.8, 51.4 ± 8.5, 42.6 ± 8.1, respectively. Following the distribution-based method for MCID calculation, we found the following MCID values for PROMIS-UE, PROMIS-PI, and PROMIS-D: 3.1, 2.7, and 4.6, respectively. ROC analysis revealed strong predictive ability for PROMIS-UE (AUC = 0.717, p < 0.05), moderative predictive ability for PROMIS-PI (AUC = 0.634, p < 0.05), and excellent predictive ability for PROMIS-D (AUC = 0.864, p < 0.05). Specifically, preoperative cutoff values of <26.0, >70.0, and >52.5 for PROMIS-UE, PROMIS-PI, and PROMIS-D are especially predictive of achieving MCID.ConclusionsPreoperative baseline scores can serve as strong predictors of success in patients undergoing primary reverse shoulder arthroplasty and can be used to both counsel patients on surgery and to tailor postoperative protocols.Level of evidenceLevel II.     

Is distal peripheral neuropathy common after shoulder arthroplasty?

BackgroundNeurologic injury after shoulder arthroplasty has been reported in previous outcome studies. However, the incidence and development of distal peripheral neuropathy (DPN) after shoulder arthroplasty requiring surgical intervention has not been previously described.HypothesisThe authors report on the incidence of DPN requiring surgical intervention following shoulder arthroplasty.MethodsA retrospective review was conducted of a prospectively collected shoulder arthroplasty registry at a single institution from a single surgeon from April 2006 to April 2017. Patients were included in the series if they had primary surgical intervention for ipsilateral or contralateral peripheral neuropathy following primary shoulder arthroplasty. Patients were excluded if they had known peripheral neuropathy or cervical radiculopathy prior to surgery. DPN was defined for the study as symptoms or diagnostic testing consistent with cubital tunnel or carpal tunnel syndrome. Demographics, patient reported outcome measures, and preoperative and postoperative shoulder range of motion were collected and analyzed with paired t-tests and multivariate regression models.ResultsOne thousand three hundred eighty-seven total shoulder arthroplasties were performed in this period. During the study period, 16 patients (1.2%) underwent surgery for ipsilateral DPN while 6 patients (0.4%) underwent surgery for contralateral DPN. ASES scores, SANE scores, and shoulder flexion improved significantly from pre- to postoperatively for both groups. There was no significant difference in postoperative scores between groups. Finally, the multivariate linear analysis did not yield any statistically significant regression equations for ASES, SANE VAS, AFE, and AER.ConclusionShoulder arthroplasty resulted in increased ipsilateral distal peripheral neuropathy. Emergence of DPN symptoms following arthroplasty is multifactorial and may be related to a form of the double crush syndrome.Level of evidenceLevel IV; Case series     

Predictors of patient satisfaction and outcomes following reverse total shoulder arthroplasty

BackgroundObjective clinical outcomes and patient satisfaction via patient reported outcome measures (PROMs) can vary following reverse total shoulder arthroplasty (rTSA). The purpose of this study was to analyze patient specific preoperative factors that may predict postoperative PROMs and satisfaction following rTSA.MethodProspective data was collected on 144 consecutive patients who underwent primary rTSA at our institution between 2012 and 2018, all with minimum 2 year follow-up. Age, gender, race, BMI, previous surgery on the index shoulder, and comorbidity burden were analyzed as potential predictors. Shoulder specific clinical measures were collected both pre- and postoperatively via range of motion testing with active abduction, internal, and external rotation. PROMs included global shoulder function, Simple Shoulder Test (SST) and the American Shoulder and Elbow Surgeons (ASES) scoring systems, and cumulative patient satisfaction. Statistical analysis included comparison of pre- and postoperative outcome measures across the cohort as a whole and between each of the potential predictors in question. The relationship between predictors and postoperative cumulative satisfaction was investigated, with specific attention to identify the strongest predictors and account for confounding variables. Statistical significance was determined at P < .05.ResultsAll range of motion scores and PROMs were significantly improved from preoperative to postoperative assessment. Patient satisfaction was excellent with 92% rating their shoulder as “much better” or “better.” Women and minority patients displayed significantly worse preoperative active abduction, SST, and ASES, but were found to have no significant difference in these measures postoperatively. Younger age was associated with a significantly worse postoperative ASES score. Female sex was associated with significantly higher postoperative satisfaction, while minority status was associated with significantly lower cumulative satisfaction. Postoperative global shoulder function, SST, and ASES were not significantly influenced by sex, race, previous surgery, BMI, or comorbidity burden. Postoperative ASES and global shoulder function demonstrated to be independent predictors of “much better” satisfaction rating.ConclusionPostoperative PROMs and cumulative satisfaction are not influenced by BMI, previous surgery, or comorbidity burden in our cohort. Relative to their respective counterparts, older patients, females, and white patients are more likely to demonstrate higher satisfaction with their outcome following rTSA as measured by PROMs or cumulative satisfaction. Improvements in the ASES and global shoulder function scores most consistently predict higher postoperative satisfaction.Level of evidenceLevel IV; Case Series; Treatment Study     

The effect of humeral stem alignment in reverse shoulder arthroplasty

BackgroundThe impact of stem alignment on hip arthroplasty outcomes has been thoroughly evaluated, but there is limited data assessing this relationship in reverse shoulder arthroplasty (RSA). In this study, we investigated the association of humeral stem alignment with patient outcomes following RSA.MethodsUsing our prospectively maintained institutional registry, we identified patients who underwent reverse shoulder arthroplasty between July 2015 and September 2017 with minimum 2-year follow-up. Two raters independently assessed stem alignment using full-length humeral view radiographs. Stem alignment was correlated to American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, range of motion, complications, and scapular notching at 2-year follow-up.ResultsOf the 117 patients that fit our inclusion criteria, 68 (58%) had neutral or valgus alignment and 49 (42%) had varus alignment. ASES score, VAS pain score, range of motion, complications, and scapular notching showed no differences between the 2 cohorts at 2-years postoperatively. Change (mean, SD) in ASES scores (52.5 ± 17.7 vs. 41.3 ± 21.2, P = .01) and VAS pain scores (−5.7 ± 2.5 vs. −4.6 ± 2.6, P = .02) were greater in the neutral/valgus cohort compared to the varus cohort. Demographics analysis revealed that the neutral or valgus cohort had a larger female population (74% vs. 59%, P < .01) while men were more likely to be in the varus cohort.ConclusionHumeral stem alignment does not appear to affect clinical outcomes at 2-years postoperatively. Improvement in ASES score and VAS pain score were slightly inferior in varus patients, however this difference was not clinically relevant. There may be a correlation between male gender and varus alignment, likely due to better bone quality and larger musculature. Further investigation into the association between stem angulation and clinical outcomes is warranted.Levels of EvidenceLevel III; Retrospective Cohort Study.     

MRI-Based Shoulder Osteoarthritis Severity score (SOAS) is predictive of functional improvement following total shoulder arthroplasty

BackgroundTotal shoulder arthroplasty (TSA) is an increasingly common treatment for end-stage glenohumeral osteoarthritis. Current established radiographic measures and classification systems do not predict patient-reported outcomes from TSA. We hypothesized that the MRI-based Shoulder Osteoarthritis Severity (SOAS) Score would correlate with subjective improvement following TSA.MethodsPatients undergoing TSA with preoperative shoulder MRIs and pre- and postoperative ASES scores with minimum 2-year follow-up were included from a prospectively collected institutional shoulder arthroplasty database. SOAS scores, which is measured from 0 to 100 with an increasing score reflecting greater global degenerative changes, were assessed by two independent reviewers, and Samilson-Prieto grade and Walch classification were scored by one reviewer. Average SOAS scores were correlated with demographic factors and pre-, post-, and change (Δ) in ASES scores. Statistical analysis was performed with STATA with Pearson's correlation, one-way ANOVA, and ROC analysis, with significance defined by p <.05.Results30 patients (age 63 ± 10 years, 14 females, 16 males) who underwent primary anatomic TSA were included. The intraclass correlation coefficient (ICC) for total SOAS scores calculated by reviewers was 0.91. SOAS score correlated significantly with ΔASES (r = 0.61, p = .0003) and preoperative ASES (r = -0.37, p = .042), with greater MRI-based degenerative change associated with greater improvement after TSA and lower preoperative ASES score. No significant relationship was found between either Samilson-Prieto or Walch classification and SOAS or ASES scores. No significant relationship was found between SOAS scores and age, sex, or BMI. Using an MCID of 21 as previously reported, an ROC curve was generated and found to have an AUC of 0.96. A SOAS score cut-point of 36.25 was found to maximize sensitivity and specificity in predicting reaching MCID.ConclusionWe observed a significant positive correlation between the MRI-based SOAS score and functional improvement following TSA measured using change in ASES scores, indicating that patients with more advanced degenerative changes on MRI had greater improvement after shoulder replacement surgery. We found that the correlation strength was highest when comparing total SOAS score to ΔASES as opposed to any individual sub-component of the SOAS score. The MRI-based SOAS score for shoulder osteoarthritis may be a valuable tool for predicting patient outcomes following TSA.Level of evidenceLevel III; Retrospective Cohort Comparison; Prognosis Study     

Effect of Weight Change on Patient-Reported Outcomes Following Total Joint Arthroplasty

BackgroundIncreased body mass index (BMI) has been previously described as a risk factor for complications after total joint arthroplasty (TJA); however, its effect on patient-reported outcomes has not been thoroughly investigated. This study examines the effect of postoperative weight change on the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) scores for total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients.MethodsA retrospective review of 988 patients undergoing THA or TKA was performed. PROMIS-PF scores and BMI were recorded throughout the study duration. Patients were classified by a 5% change in BMI. A univariate analysis evaluated differences across groups. Mixed-effect models evaluated predictors of change in functional score over the postoperative follow-up time.Results43.1% patients had a THA and 56.9% patients had a TKA. At 0 to 3 months, 92% of patients had no change in BMI, 3 to 6 months 82% had no change, and 6 to 12 months 80% had no change. There were no significant demographic or comorbidity differences across groups for both THA and TKA. Similar improvements in PROMIS-PF scores were observed across weight change groups. In the mixed-effect models, postoperative time was found to be a significant predictor of postoperative PF score. Both THA and TKA patients saw greater improvements in PROMIS-PF scores in patients with lower preoperative BMIs.ConclusionThese results demonstrate most patients do not experience substantial changes in weight following TJA. However, lower BMIs at the time of surgery were associated with an increased functional improvement. Therefore, efforts to optimize BMI should be focused preoperatively to improve surgical outcomes.     

反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂

目的探讨反式全肩关节置换术治疗盂肱关节骨关节炎合并巨大肩袖撕裂的近期临床疗效。 方法回顾性分析2016年1月至2018年12月在南部战区总医院接受初次反式全肩关节置换术治疗的15例盂肱关节骨关节炎合并巨大肩袖撕裂患者,均有肩关节持续性疼痛、功能障碍,且三角肌无损伤具有功能;排除有臂丛或腋神经损伤以及有肩关节手术史的患者。评估其术前、术后1年的肩关节主动活动度,使用美国肩肘外科协会(ASES)肩关节评分、加州大学洛杉矶分校(UCLA)最终结果评分评价肩关节功能,分析X线及CT并发症出现情况。采用配对t检验对术前及术后的活动度和评分差异进行性分析。 结果15例患者均顺利完成手术并获得随访,随访时间17个月(范围12～36个月)。反式全肩关节置换术后1年肩关节主动前屈(124±11)°较术前(58±18)°提高(t＝14.316,P<0.01),外展(120±12)°较术前(58±20)°提高(t＝9.959,P<0.01),内旋较术前改善,外旋(26±8)°较术前(25±9)°无明显变化(t＝1.598,P>0.05),术后1年ASES评分(78±7)显著高于术前(33±8)(t＝16.487,P<0.01);术后1年UCLA评分(31±4)显著高于术前(15±3)(t＝12.826,P<0.01)。 结论RTSA能够有效治疗盂肱关节骨关节炎合并巨大肩袖撕裂,取得了良好的早期临床效果,但术后肩关节外旋无明显改善,术前需评价小圆肌情况以确定相关治疗方案。     

Shoulder replacement in end-stage rotator cuff tear arthropathy: 5- to 11-year follow-up analysis of the bi-polar shoulder prosthesis

Between 1991 and 1997, 49 patients with rotator cuff arthropathy underwent 52 Bi-Polar shoulder replacements and were followed for 5-11 years (average follow-up 6.7 years). Active forward flexion increased an average of 35.2 degrees (from 45 degrees preoperatively to 80.2 degrees postoperatively). UCLA scores improved from 8.4 (range 4-16) preoperatively to 24.3 (range 15-35) postoperatively. Average age- and sex-adjusted Constant scores were 83.4% and ASES index was 68.5 points at the time of final review. Two shoulders (3.8%) were revised--both secondary to periprosthetic fracture requiring long-stem implants. Probability of survival at 11 years using Kaplan-Meier survival estimates was 93.3% (95% Cl: 84%-100%). Bipolar shoulder arthroplasty is an effective way to treat end-stage rotator cuff arthropathy with clinical results as good or better than those reported in the literature for hemiarthroplasty and total shoulder replacement with reasonable follow-up.     

The Association Between Anxiety,Depression, and Locus of Control With Patient Outcomes Following Total Knee Arthroplasty

BackgroundWe aimed to determine how preoperative anxiety, depression, and locus of control (LoC) might predict patient outcomes following total knee arthroplasty (TKA).MethodsPatients undergoing TKA were prospectively recruited over an 18-month period. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess TKA outcomes. The Short Form-12, Hospital Anxiety and Depression Score, and LoC surveys were completed by the patients to assess their psychosocial state. These scores were collected preoperatively and at 6 weeks, 18 weeks, and 1 year postoperation.ResultsThe final cohort consisted of 136 patients. Greater preoperative depression (P = .004) and anxiety (P = .001) scores were correlated with worse total WOMAC score at 6 weeks and 18 weeks postoperatively, respectively. A poorer preoperative Short Form-12 mental score was also correlated with a worse total WOMAC score at 6 weeks postoperatively (P = .007). Greater tendency toward an internal LoC preoperatively was correlated with better WOMAC pain (P < .001) and function (P = .003) scores at 18 weeks postoperatively. However, there was no correlation between preoperative external LoC and postoperative WOMAC score. There was also no correlation between any of the preoperative psychosocial measures and WOMAC score at 1 year postoperatively.ConclusionWe identified a group of patients whose psychosocial markers predicted them to have worse outcomes in the short to medium term even though they normalized to satisfactory outcomes at 1 year postoperatively. Identifying this group could allow for targeted intervention with an adjustment of expectations and thus more effective recovery.     

Clinical and patient-reported outcomes of reverse shoulder arthroplasty in patients receiving Social Security Disability Insurance or workers’ compensation

BackgroundEvidence suggests that reverse shoulder arthroplasty (RSA) patients receiving workers’ compensation (WC) have worse patient-reported outcomes (PROs) than those not receiving WC. It is unknown whether Social Security Disability Insurance (SSDI) recipients also have worse outcomes of RSA. Our goals were to (1) compare PROs and range of motion (ROM) after RSA according to whether patients were receiving SSDI, WC, or neither form of assistance, and (2) identify factors associated with poor PROs.MethodsFrom a US institutional database of 454 patients who underwent RSA from January 2009 through December 2016, we identified 19 SSDI recipients and 25 WC recipients. From the same database, we created a control group of 81 patients not receiving SSDI or WC, matched by demographic variables. Between groups, we compared age, sex, operative arm dominance, preoperative diagnosis, number of previous shoulder surgeries, primary or revision arthroplasty, and Charlson Comorbidity Index value. Patients were evaluated preoperatively and at a minimum of 2 years postoperatively by physical examination, including range of motion, visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, L'Insalata score, Simple Shoulder Test (SST), and Western Ontario Osteoarthritis of the Shoulder (WOOS) score. Significance was set at P< .05. Clinical relevance of improvements in forward flexion and abduction, VAS for pain, ASES, and SST were evaluated using established minimal clinically important difference (MCID) values.ResultsBoth the SSDI and WC groups experienced statistically significant improvements from preoperatively to postoperatively; these improvements exceeded MCID thresholds for forward flexion and abduction, VAS for pain, ASES (except in WC group), and SST score (all, P< .05). These outcomes were not significantly different between the SSDI and WC groups. Compared with the control group, both the SSDI and WC groups had statistically significantly worse outcomes for these same measures. The only factor associated with poor clinical outcomes was having undergone ≥2 previous surgical procedures on the same shoulder for which RSA was performed in both SSDI (odds ratio = 2.4, 95% confidence interval: 1.0-5.4) and WC (odds ratio = 1.6, 95% confidence interval: 1.1-4.5) groups.ConclusionAmong RSA patients, SSDI recipients did not have worse clinical outcomes than WC recipients. Having undergone ≥2 previous procedures on the same shoulder was associated with poor outcomes in both groups. These findings should be considered when determining the appropriateness of RSA for SSDI and WC recipients.Level of evidenceLevel III; Retrospective Cohort Comparison; Treatment Study     

The influence of computed tomography preoperative planning on clinical outcomes after anatomic total shoulder arthroplasty: a matched cohort analysis

BackgroundEvaluation, characterization, and correction of glenoid deformity are an important part of performing anatomic total shoulder arthroplasty (TSA). Three-dimensional computed tomography (3D CT) planning has been shown to improve implant position, but the impact on clinical outcomes is less clear. The purpose of the current study is to compare clinical outcomes of TSA performed with 3D CT preoperative planning with matched controls performed without CT-based planning.MethodsUtilizing a multicenter shoulder arthroplasty registry, patients who underwent a TSA with 2-year clinical follow-up were retrospectively identified. These patients were divided into two cohorts based on technique for glenoid guide pin placement based on surgeon preference: 1) those who utilized 3D preoperative templating with or without patient-specific instrumentation (PSI) and 2) a control group of TSAs performed without 3D CT preoperative planning. The two groups were matched 1:1 based on age, sex, and baseline American Shoulder and Elbow Surgeons (ASES) score. Patient-reported outcomes and active range of motion (ROM) obtained at 2 years postoperatively were assessed and compared between the two cohorts. A subgroup analysis was also performed comparing outcomes in patients with 3D CT preoperative planning with and without PSI.ResultsData collection was performed on 84 study patients with 3D CT preoperative planning (51 with PSI and 33 without) and 84 matched control patients without CT-based planning (168 patients in total). Baseline characteristics were similar between the groups. Improvement from baseline for the ASES score (study group: 45.4, controls: 39.0, P = .029) and external rotation at 90^° of abduction (study group: 42^° vs. 29^°, P = .009) was significantly greater in the CT-based planning group than that in matched controls. There were no other significant differences in improvement in outcomes or ROM between the two groups. Within the 3D CT cohort, there were no significant differences in patient-reported outcomes or ROM between TSAs performed with or without PSI. A significantly greater percentage of patients with 3D CT planning achieved a patient acceptable symptomatic state than controls (89% vs. 75%, P = .016).ConclusionTSAs performed with 3D CT preoperative glenoid planning with or without utilization of PSI were associated with statistically significantly greater improvement from baseline in ASES scores and external rotation at 90^° of abduction than TSA performed without 3D CT planning. The clinical significance of this finding is unclear, as the differences failed to meet a clinically significant threshold.     

Clinical application of intraoperative O-arm navigation in reverse shoulder arthroplasty

BackgroundInaccurate fixation and positioning of the glenoid component using conventional techniques are problematic in reversed shoulder arthroplasty (RSA). Our objective was to investigate the accuracy of O-arm navigation of the glenoid component in RSA.MethodsThis retrospective case–control study comprised 2 groups of 25 patients who underwent reversed shoulder arthroplasty with or without intraoperative O-arm navigation. The intraoperative goal was to place the component neutrally in the glenoid in the axial plane and 10° inferiorly tilted in the scapular plane. Glenoid version angle and inclination were measured by computed tomography obtained preoperatively and a year postoperatively. Operative time, intraoperative bleeding, and the presence of postoperative complications were recorded.ResultsCompared with the ideal, the range of error for version was 7.3° (SD 3.6°) in the control group and 5.6° (SD 3.6°) in the navigated group (P = 0.278), and the range of error for inclination was 18.3° (SD 11.7°) in the control group and 4.9° (SD 3.8°) in the navigated group (P = 0.0004). The mean operative time was 164.6 (SD 21.2) min in the control group and 192.0 (SD 16.2) min in the navigated group (P = 0.001). The mean intraoperative bleeding was 201.0 (SD 37.0) mL in the control group and 185.3 (SD 35.6) mL in the navigated group (P = 0.300). There were no complications reported related to the intraoperative O-arm navigation.ConclusionO-arm navigation may be a useful tool for the placement with inferior tilt of the glenoid procedure in reversed shoulder arthroplasty.     

Impact of age within younger populations on outcomes following cervical surgery in the ambulatory setting

ObjectiveTo determine the effect of age within the younger population seen at ambulatory surgical centers on patient-reported outcome measures (PROMs) after cervical spine surgery.MethodsPatients of age <65 years undergoing single-level anterior cervical discectomy and fusion (ACDF) or cervical disc replacement (CDR) were included. Patients were divided by mean age of initial population (46 years). PROMs included Patient-reported Outcome Measurement Information System Physical Function (PROMIS-PF), 12-Item Short-Form Physical Component Survey (SF-12 PCS), Visual Analog Scale (VAS) neck, VAS arm, Neck Disability Index (NDI) collected preoperatively and at postoperative time points up to 2 years.Results138 patients were included, with 66 patients <46 years. Both cohorts demonstrated improvement from preoperative baseline with regard to all studied PROMs at multiple time points postoperatively (p ≤ 0.042, all). Between groups, the older cohort demonstrated greater mean PROMIS-PF scores preoperatively and at 6 weeks (p ≤ 0.011, both), while VAS arm scores were lower in the older group at 1 year (p = 0.002), and NDI scores were lower in the older group at 6 weeks and 1 year (p < 0.027, both). Minimal Clinically Important Difference (MCID) achievement rates were greater in the younger group in PROMIS PF at 2 years (p = 0.002), and in the older group in VAS arm score at 1 year (p = 0.007).ConclusionBoth cohorts showed significant improvement at multiple postoperative time points for all PROMs. Between groups, the older group reported more favorable physical function, VAS arm, and NDI scores at several time points. However, MCID achievement rates only significantly differed in two PROMs at singular time points. Difference in age in patients <65 years likely does not significantly affect long-term outcomes after cervical spine surgery.     

Does diabetes affect functional outcomes after shoulder arthroplasty?

ObjectivesThe purpose of this study was to assess whether diabetes affects functional and physical outcomes following shoulder arthroplastyMethodsA cohort of 140 patients were tested preoperatively, at an early follow-up visit (between 3-6 months) and at late follow-up visit (between 1-3 years) following shoulder arthroplasty. The American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form measured shoulder pain and function and the Short-Form-12 (SF-12) measured physical health status. Shoulder goniometry and dynamometry were used to assess motion and strength. Diabetic status was self-reported.ResultsThere were significant improvements in function and physical health status for both diabetic and nondiabetic patients at the late follow-up visit. For patients with diabetes, shoulder function (ASES: 0-30) improved from 5 (5) to 18 (6) scores (p < 0.001) and physical health status improved from 27 (6) to 38 (8) scores (p < 0.001). For patients without diabetes, shoulder function improved from 8 (5) to 19 (8) scores (p < 0.001) and physical health status improved from 31 (8) to 40 (12) scores (p < 0.001). No significant differences between diabetic and nondiabetic patients was detected at the late follow-up.ConclusionPatients with diabetes achieve large clinical benefits from shoulder arthroplasty, with follow-up outcomes equally positive to those without diabetes. Future prospective studies with a larger sample size of patients with diabetes are needed to confirm the results of this study.Level of evidenceII     

Urinary tract infections diagnosed within two weeks prior to shoulder arthroplasty are associated with increased postoperative infection rates

BackgroundAlthough literature describing the increased risk of postoperative infection for patients undergoing lower extremity arthroplasty with a preoperative urinary tract infection (UTI) is inconclusive, this relationship has yet to be adequately studied for shoulder arthroplasty. The goals of the present study were to examine the association between preoperative UTIs and their timing with periprosthetic joint infection (PJI) after shoulder arthroplasty.MethodsPatients undergoing primary shoulder arthroplasty diagnosed with a UTI in the preoperative period were identified in an insurance database and separated into mutually exclusive groups based on one-week intervals up to six weeks before surgery. A matched control cohort without a preoperative UTI was created for comparison. The incidence of PJI within two years after shoulder arthroplasty was then assessed for each cohort and compared using a logistic regression analysis.ResultsCompared with matched controls, patients with a UTI diagnosed within 1 week before shoulder arthroplasty (odds ratio, 2.73; 95% confidence interval, 1.67-4.46; P < .001) and within 1 to 2 weeks preoperatively (odds ratio, 1.77; 95% confidence interval, 1.24-2.52; P = .002) experienced significantly higher rates of PJI within 2 years postoperatively. There were no significant differences in the incidence of PJI between patients diagnosed with a UTI greater than 2 weeks before surgery and matched controls (P > .05).ConclusionPatients diagnosed with a UTI within 2 weeks before shoulder arthroplasty may be at an increased risk of postoperative PJI.Level of evidenceLevel III, Database Case-control Prognosis Study     

Glenosphere inclination and clinical outcomes after reverse shoulder arthroplasty

BackgroundThe relationship of numerous implant design and positioning-related variables with range of motion and clinical outcomes have been investigated for reverse shoulder arthroplasty (RSA). While glenosphere inclination has been investigated with regards to implant fixation and scapular notching, little research has been done on the association between glenosphere inclination and clinical outcomes. Therefore, the primary objective of this study was to investigate the relationship between preoperative glenoid inclination, postoperative glenosphere inclination and inclination change (∆INC) from pre- to postoperative on clinical outcomes after RSA.MethodsA multicenter retrospective study was conducted of RSAs with minimum 2-year clinical follow-up. All included patients had the same RSA prosthesis. Preoperative, postoperative, and ∆INC from pre-to postoperatively were measured for each patient. The primary study outcome was the minimum 2-year ASES score. Secondary outcomes were active range of motion, Constant-Murley score and Western Ontario Ostearthritis Shoulder (WOOS) score at a minimum of 2 years postoperatively. Receiver-operator characteristic curve analyses were performed to determine if any significant thresholds in inclination existed. Univariate analyses were performed with ANOVA to compare subgroup means. Finally, a multivariate logistic regression was performed to examine each inclination variable as a predictor of clinical outcome while controlling for patient and implant-related variables.ResultsEighty seven patients were included in the study. The mean age was 70 years and 53% of patients were male. The examiners had excellent reliability determined by intraclass correlation coefficients for all 3 measurements. There was no apparent correlation between preoperative inclination, postoperative inclination or ∆INC with minimum 2-year ASES scores. This was confirmed in the receiver-operator characteristic analyses, where no significant thresholds were found for each of the 3 assessed measurements (P> .05 for all analyses). A subgroup analysis comparing patients with low preoperative inclination (<10°) and patients with high preoperative inclination (>10°) stratified by the ∆INC demonstrated no significant association with inclination (P > .05 for all comparisons). In the multivariate regression analysis, inclination had no significant association with the minimum 2-year ASES scores.ConclusionFor the studied implant system, preoperative inclination, postoperative inclination and ∆INC did not have a significant association with postoperative clinical outcomes after RSA.Level of evidenceLevel III; Retrospective Comparison Study