Functional Outcome After Total Shoulder Arthroplasty:

Lawrence V. Gulotta, MD

Sports Medicine and Shoulder Service

Hospital for Special Surgery

Can Perioperative Factors be Predictive?

I Lawrence V. Gulotta am a consultant for Biomet, Inc,

Level of Evidence: IV

BackgroundTSA has excellent clinical track record

• JSES 2002 (Norris et al)– Multicenter study– 95% good/excellent results– Hemi/TSA

• JSES 2005 (Thornhill)– Survivorship 85% @ 20 years– DASH/survivorship

• JBJS 2003 (Iannotti et al)– Glenoid bone erosion &

humeral head subluxation worse outcome– Hemi/TSA

Background

Most studies combine TSA’s and Hemi’s, or use non-validated outcomes scores.

Purpose

• To determine if perioperative patient and radiographic factors can predict functional outcomes for patients undergoing primary total shoulder arthroplasty?

Methods

Inclusion•Prospective registry data •1°TSA for OA •Baseline & 2 year data

Exclusion•Patients not captured•Dx other than OA•Revision case

Shoulder Arthroplasty Registry

• Prospective data collection– 2007 - present (ongoing)– 22 surgeons

• Enrollment– All patients undergoing shoulder arthroplasty at HSS

• Data

DemographicsMedical HIstoryASES Score

Details of ProcedureComplications

ComplicationsASESSatisfaction

ComplicationsASESSatisfaction

Baseline Intra-Op 2 Year 5 Year

Shoulder Arthroplasty Registry

1190 Patients Enrolled

Shoulder Arthroplasty Registry

Patient Factors

•Gender•Age•Diagnosis•Side•ASA status•Heart disease•Lung disease•Diabetes•Cuff status

*whether or not they underwent reoperation

Preoperative X-rays

Glenoid bone loss•<5mm•5-10mm•>10mm

Humeral Head Sblx•> 25% considered abnormal

JBJS 2003;85:21-258

Postoperative X-rays

Glenoid Version– Gerber’s α angle

Humeral head height– Tuberosity in relation to

head

JSES 2003;12:493-6Eur J Rad 2008;68:159-69

> 10 degrees considered poor >10mm considered “overstuffed”

Functional Outcome

Defined by American Shoulder Elbow Surgeon Assessment Form (ASES)

– Primary PRO at baseline & 2-year f/u– 50 points as cut-off (poor)

Michener et al– Valid, responsive, reliable, & internally consistent– MCID ~ 6.4 points– MDC ~ 9.4 points– Minimal (66), moderate (45), & maximal (40.7) limitation

JSES 2002;11:587-94Arthritis Care and Research 2009;61:623-32

Statistical Methods

•Univariate analysis of potential risk factors and outcome of interest

•Multivariate logistic regression analysis– Control confounding effects– Adjust for other risk factors in model

•p < 0.05 = significant

•Crude OR for each factor– Independent association btwn risk factor and outcome

Results

Patients Characteristics

• 189 shoulders– 214 Eligible (88% f/u rate)

• Average age 66 yo (40-85)• 52.4% male; 47.6% female

– 12.6% w/ heart disease– 5.4% w/ lung disease– 6% w/ diabetes– 2.7% w/ cuff tear

Results

Measurement Total N Percentage

Glenoid Erosion

< 5mm 126 69%

5-10mm 43 24%

>10mm 12 7%

HH Sblx

Yes 20 11%

no 163 89%

Preoperative Measurements

Results

Measurement Average Range

Prosthesis Height 4.8 mm -3 to 12 mm

Glenoid Version -6.9° -20 to 2°

Postoperative Measurements

Results

Overall ASES Scores

Mean SD

Baseline 35.72 17.32

2-year 85.51 13.68

Change 49.79

p-value (w/in group) <0.0001

Five patients needed repeat surgery (4%) Eight patients failed to reach ASES of 50

96% Good Functional Result

Results

Good vs Poor ASES Scores

> 50 (181) < 50 (8)

Mean SD Mean SD p-value

Baseline 38.92 16.44 24.50 15.02 0.016

2-year 87.51 12.77 28.46 12.90 <0.001

Change 48.59 20 3.96 14.17 <0.001

p-value (w/in group)

<0.0001 0.573

Why did these patients do so poorly?

Analysis  Crude 95% CI 95% CI Adjusted 95% CI 95% CI  

Variable OR Lower Upper OR Lower Upper p-value

Age at surgery 1.09 0.99 1.20 1.11 0.96 1.29 0.050

Female sex 3.46 0.68 17.62 --- --- --- ---

Non-OA diagnosis 3.86 0.40 37.35 --- --- --- ---

Bilateral 0.00 0.00 0.00 --- --- --- ---

*Repeat surgery on the joint replaced* 4.17 0.44 39.44 --- --- --- ---

Cuff Repair Performed 10.50 0.85 130.16 --- --- --- ---

Heart disease 5.11 0.79 33.11 --- --- --- ---

Lung Disease 7.00 1.22 40.30 13.71 1.28 147.26 0.031

Diabetes 12.60 2.55 62.25 11.97 1.01 142.42 0.049

*PRE Glenoid erosion* 0.44 0.07 3.03 --- --- --- ---

*PRE HH subluxation (+)* 0.00 0.00 0.00 --- --- --- ---POST Abnormal humeral head height (outside 2-5mm) 0.20 0.02 1.84 --- --- --- ---

*POST Overstuffed HH height (>10mm)* 1.07 0.11 10.52 --- --- --- ---

POST Abnormal glenoid version 1.27 0.20 7.96 --- --- --- ---

*POST Glenoid version <-10 deg* 0.87 0.07 10.01 --- --- --- ---

What happened to those 8 patients?

Chart review and personal contact• 2 subscapularis ruptures

– x1 attempted repair (failed)– x1 w/ noncompliance (subjectively ok)

• 2 w/ significant cervical radiculopathy

• 1 w/ global cuff weakness

• 1 w/ significant preop AVN

• 2 w/ apparent good subjective result

*preop ASES avg 25

Reoperations: 5 total

• 3 subscapularis repairs– 3 to 5 months postop– avg age 72 years (63-84)– NONE HEALED– 2 went on to have poor result– 1 went on to have good result

• 2 biceps tenodeses• No Early Loosening• No Posterior Instability

Conclusions•TSA offers excellent short term functional results

•Significant gains in ASES (~50 points)

•Predictors for poor result– Age, Diabetes, and lung disease -> Patient Expectations– Very low preop ASES score

•Subscapularis rupture: #1 reoperation- LTO?, Subscap Sparing TSA?, Primary RSA?- Subscap repair often not successful -> RSA

•Address the biceps: #2 reoperation

Strengths• Prospective• Registry data• Multiple surgeons• Patient & surgical factors assessed• TSA only (hemi’s excluded)• Validated Outcome

Weaknesses• Short-term

Special Thanks• Fellow

– Brian Grawe, MD• Stats

– Joe Nguyen– Emily Lai

• Research Coordinator– Sherrie Vassallo

• RA– Greg Mahony

• Contributing Surgeons– Drs. Craig, Dines, Warren, and shoulder registry group

Thank You