Measuring outcomes in shoulder arthroplasty

No standard assessment for the patient with a shoulder arthroplasty has been universally accepted to date. Traditional assessment tools can be divided into three levels of resolution including: (1) assessments of the quality of life and general health, (2) global shoulder assessments, and (3) assessments for a particular disorder of the shoulder. In this article, examples of each of these groups are discussed. Each of these levels of sensitivity offers a different perspective on the outcome of shoulder arthroplasty and until the ideal, universal outcome measure is developed, outcomes should be reported using assessments in each of these levels.     

Midterm outcomes of revision shoulder arthroplasty

BackgroundSince the introduction of shoulder arthroplasty, the indications have been expanding. Because of the increasing number of arthroplasty procedures, revision surgeries are also inevitable. The purpose of our study is to delineate a large number of revision shoulder arthroplasty cases treated in different ways, including antibiotic spacer placement (ABX), hemiarthroplasty (HA), anatomic total shoulder arthroplasty (aTSA), and reverse total shoulder arthroplasty (rTSA), and to analyze the relationship between preoperative factors and clinical outcomes.MethodsWe reviewed our institution's records of revision shoulder arthroplasty between January 1, 2000, and October 1, 2017. Preoperative information included age at the time of surgery, gender, body mass index, and infection status. Pre- and postoperatively, we gathered 6 patient-reported clinical outcomes and 3 range-of-motion parameters (elevation, abduction, and external rotation). Postoperative complications were also assessed. Then, we examined the differences between the pre- and postoperative outcomes. As a secondary analysis, we performed multivariable regression analysis on the same outcomes, accounting for age at the time of surgery, infection status, and previous surgery type.ResultsAmong the 341 revisions performed, 138 cases met inclusion criteria of at least a 2-year follow-up with pre- and postoperative functional outcome scores. The majority of our revision procedures were to a rTSA (92 cases, 67%), followed by aTSA (28 cases, 20%), and ABX/HA (18 cases, 13%). The mean age at the time of our index surgery was 66 years old. In aTSA and rTSA, all the postoperative outcomes (ie, ASES, Constant, UCLA, SST, SPADI, SF-12 scores, and 3 AROMs) were significantly improved beyond the minimal clinically important difference (MCID) except SF-12 scores in aTSA (P = .25) and active external rotation in rTSA (P = .73). None of the ABX/HA's postoperative outcomes achieve significant improvement or MCID. Multivariable regression analysis showed that older age at the time of surgery was significantly associated with better outcomes in 3 of the 6 patient-reported outcomes (ASES, SST, and SPADI; P = .023, .023, and .028, respectively).ConclusionRevision aTSA and rTSA showed statistically and clinically significant improvement postoperatively. ABX and HA did not achieve meaningful postoperative improvement. Overall, patients getting revision shoulder arthroplasty at an older age had better patient-reported outcomes.Level of evidenceLevel III; Retrospective Cohort Study     

Arthroplasty costs excluding implants: anatomic total shoulder versus reverse shoulder arthroplasty

BackgroundThe incidence of reverse total shoulder arthroplasty (rTSA) has been rising exponentially in recent years. Compared to anatomic total shoulder arthroplasty (aTSA), rTSA incurs higher total hospital costs, largely due to implant prices. However, rTSA typically requires less operating room (OR) time and is a cementless procedure, potentially representing important cost savings. Our aim is (1) to evaluate the difference in total hospital costs for rTSA and aTSA excluding implant costs and (2) to identify cost factors between the two procedures. Our hypothesis is that rTSAs and aTSAs will have similar costs excluding implants due to offsetting personnel and supply costs.MethodsTime-driven activity-based costing was utilized to determine the costs of rTSAs and aTSAs at our single-specialty hospital from January 2018 to 2020. Implant costs were subtracted from total hospital costs to determine costs excluding implants. Other demographic and cost parameters were also compared.ResultsNine hundred twenty-one primary shoulder procedures were analyzed (577 rTSAs and 344 aTSAs). Patients undergoing rTSA were significantly older, had a larger American Society of Anesthesiologists classification, had a longer length of stay, and were more likely to have Medicare as the primary insurance. Additionally, patients undergoing rTSA had significantly less OR time and fewer home discharges (P < .05). However, excluding implants, supply costs and overall hospital costs were 0.86× and 1.01× the cost of aTSA, respectively (P < .001 and P = .560), indicating that there was no significant difference between rTSA and aTSA overall hospital costs when omitting implant costs. Implants accounted for 97% of the difference in overall hospital costs between rTSA and aTSA.ConclusionExcluding implants, rTSA and aTSA have similar hospital costs. The savings with rTSA attributed to decreased OR time and supplies (excluding implants) are offset by personnel costs and length of stay from the postanesthesia care unit through discharge. Decreasing rTSA implant prices to the level of aTSA would equate the costs for these two procedures. As the incidence of rTSA rises, strategies to decrease implant costs are important for decreasing overall health expenditures.     

Effect of obesity on perioperative and 180-day outcomes following anatomic and reverse total shoulder arthroplasty

BackgroundAn increasing number of anatomic and reverse total shoulder arthroplasties (aTSA and rTSA, respectively) are being performed on obese patients. Current literature shows highly variable results regarding the relationship between obesity and TSA outcomes. The purpose of this study is to more clearly define the effect of obesity on complication rates and outcomes following TSA using large, national databases.MethodsThe Nationwide Inpatient Sample (NIS) database and Nationwide Readmission Database (NRD) were queried from 2011 to 2017 to identify all cases of aTSA and rTSA. These groups were further stratified into non-obese, obese, and morbidly obese cohorts. The NIS database was used to perform a demographic, hospital characteristic analysis, and peri‑operative complication analysis (n = 433,111). The NRD was then used to analyze 180-day rates of complications, revisions, mortality, extended hospital stays, non-home discharges, and overall total cost (n = 303,755).ResultsThe most obese individuals were significantly more likely to be younger, female, black, and have higher comorbidity scores (all P < .001). In the peri‑operative setting, morbid obesity was predictive of higher complication rates compared to non-obese patients following both aTSA and rTSA (both P< .001). Obesity was predictive of increased perioperative complication rates following aTSA (P = .002), but fewer complications following rTSA (P < .001). Morbid obesity was predictive of higher frequencies of 180-day complication rates, extended hospital stays, and non-home discharge following aTSA and rTSA, as well as higher rates of 180-day revision rates following rTSA (all P < .05) compared to non-obese individuals. While obesity was predictive of higher 180-day revision rates following rTSA (P < .001), it was predictive of lower rates of extended hospital stays following aTSA and rTSA (all P < .001), lower non-home discharge rates following rTSA (P = .009), lower 180-day revision rates following aTSA (P < .001), and lower 180-day complication and revision rates following rTSA (both P < .001).ConclusionsWhile obesity was predictive of higher rates of peri‑operative complications following aTSA and 180-day revision rates following rTSA, it otherwise appears to be a safe procedure in the obese population. Morbid obesity, however, appears to be predictive of increased peri‑operative and 180-day complication rates, longer hospital stays, and more frequent non-home discharge rates following TSA. Patients should be counseled appropriately on this information when considering surgery in order to facilitate shared decision making, and surgeons should take particular care when performing TSA in the morbidly obese population.Level of EvidenceLevel III; Retrospective Cohort; Treatment Study     

Perioperative complications and outcomes in patients with paraplegia following anatomic and reverse total shoulder arthroplasty

BackgroundPatients with lower extremity paraplegia utilize their upper extremities for mobilization and propulsion, which can lead to painful shoulder degeneration. Anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) are utilized for patients with paraplegia in an attempt to decrease pain and increase mobility and function of the shoulder joint. The optimal treatment and associated risks of shoulder arthroplasty surgery in patients with paraplegia are unknown. The purpose of this study is to evaluate the perioperative outcomes, length of hospital stay, and readmissions in patients with paraplegia compared to a control group without paraplegia who underwent aTSA and rTSA.MethodsThe United States Nationwide Readmission Database (NRD) was utilized for this study. To ensure that the perioperative outcomes were attributable to the total shoulder arthroplasty (TSA), patients were excluded if they had any additional invasive procedure(s) during the same hospitalization as the original TSA as long as the procedure was not an adverse outcome of interest. Seventy-nine patients with paraplegia who underwent a TSA were isolated and matched to controls without paraplegia based on arthroplasty type (aTSA vs. rTSA), sex, age, obesity status, insurance type, and median household income. Comparative differences in patient demographics, comorbidities, perioperative complications, length of stay and readmission rates were analyzed.ResultsPatients with paraplegia undergoing TSA had an increased prevalence of the following preoperative comorbidities: deficiency anemia (P < .01), congestive heart failure (P < .03), fluid and electrolyte disorders (P < .03), and depression (P < .05). They were also significantly more likely to develop a urinary tract infection or at least 1 perioperative complication (both P < .01). The median length of stay for patients with paraplegia (3 days) following TSA was significantly longer than for patients without paraplegia (1 day; P = .01), and 26.6% of patients with paraplegia were readmitted for any reason following the TSA compared to 8.9% of those without paraplegia (P < .03). Additionally, patients with paraplegia were not at an increased risk of developing an infection or receiving a revision of the TSA within the calendar year of their surgery (both P = 1).ConclusionTSA successfully relieves shoulder pain and addresses pathology in patients with paraplegia, however this study demonstrates that patients with paraplegia undergoing a TSA experience higher medical complication rates in the perioperative period, a longer hospital stay, and higher readmission rates following discharge compared to their able-bodied matched controls. These findings highlight the importance of providing special consideration for patients with paraplegia when opting for surgical interventions.Level of Evidence: Level III; Retrospective Cohort; Treatment 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     

Surgeon experience and clinical and economic outcomes for shoulder arthroplasty

BACKGROUND: Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty. METHODS: We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adjusted for procedure, age, gender, race, marital status, comorbidity, diagnosis, insurance type, income, and hospital volume. RESULTS: For the 1868 discrete total shoulder arthroplasties and hemiarthroplasties done in the state of Maryland, the risk of at least one complication associated with the procedures done by the high-volume surgeon group was nearly half that associated with the procedures done by the low-volume surgeon group (adjusted odds ratio, 0.6; 95% confidence interval, 0.4 to 0.9). High-volume surgeons were three times more likely than were low-volume surgeons to have patients with a hospital stay of less than six days (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6). Although the average cost of hospitalization was $1000 less in the high-volume surgeon group compared with the low-volume surgeon group, this reduction did not reach significance after adjustment for multiple variables (odds ratio, 0.8; 95% confidence interval, 0.5 to 1.4). CONCLUSIONS: This study indicates that the patients of surgeons with higher average annual caseloads of total shoulder arthroplasties and hemiarthroplasties have decreased complication rates and hospital lengths of stay compared with the patients of surgeons who perform fewer of these procedures. These analyses of hospital discharge data are limited because of a lack of prospective data, operative details, and patient outcomes data. However, this study emphasizes the importance of continued education for orthopaedic surgeons who perform shoulder arthroplasty.