College of Medicine, University of Florida, Gainesville, FL, USA.
Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
J Shoulder Elbow Surg. 2023 Oct;32(10):e516-e527. doi: 10.1016/j.jse.2023.03.032. Epub 2023 May 11.
When patients require revision of primary shoulder arthroplasty, revision reverse total shoulder arthroplasty (rTSA) is most commonly performed. However, defining clinically important improvement in these patients is challenging because benchmarks have not been previously defined. Our purpose was to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for outcome scores and range of motion (ROM) after revision rTSA and to quantify the proportion of patients achieving clinically relevant success.
This retrospective cohort study used a prospectively collected single-institution database of patients undergoing first revision rTSA between August 2015 and December 2019. Patients with a diagnosis of periprosthetic fracture or infection were excluded. Outcomes scores included the ASES, raw and normalized Constant, SPADI, SST, and University of California, Los Angeles (UCLA) scores. ROM measures included abduction, forward elevation (FE), external rotation (ER), and internal rotation (IR) score. Anchor-based and distribution-based methods were used to calculate the MCID, SCB, and PASS. The proportions of patients achieving each threshold were assessed.
Ninety-three revision rTSAs with minimum 2-year follow-up were evaluated. Mean age was 67 years, 56% were female, and average follow-up was 54 months. Revision rTSA was performed most commonly for failed anatomic TSA (n = 47), followed by hemiarthroplasty (n = 21), rTSA (n = 15), and resurfacing (n = 10). The indication for revision rTSA was most commonly glenoid loosening (n = 24), followed by rotator cuff failure (n = 23), subluxation and unexplained pain (n = 11 for both). The anchor-based MCID thresholds (% of patients achieving) were as follows: ASES, 20.1 (42%); normalized Constant, 12.6 (80%); UCLA, 10.2 (54%); SST, 0.9 (78%); SPADI, -18.4 (58%); abduction, 13° (83%); FE, 18° (82%); ER, 4° (49%); and IR, 0.8 (34%). The SCB thresholds (% of patients achieving) were as follows: ASES, 34.1 (25%); normalized Constant, 26.6 (43%); UCLA, 14.1 (28%); SST, 3.9 (48%); SPADI, -36.4 (33%); abduction, 20° (77%); FE, 28° (71%); ER, 15° (15%); and IR, 1.0 (29%). The PASS thresholds (% of patients achieving) were as follows: ASES, 63.5 (53%); normalized Constant, 59.1 (61%); UCLA, 25.4 (48%); SST, 7.0 (55%); SPADI, 42.4 (59%); abduction, 98° (61%); FE, 110° (56%); ER, 19° (73%); and IR, 3.3 (59%).
This study establishes thresholds for the MCID, SCB, and PASS at minimum 2-years after revision rTSA, providing physicians an evidence-based method to counsel patients and assess patient outcomes postoperatively.
当患者需要对初次肩关节置换进行翻修时，最常进行的是翻修反向全肩关节置换术（rTSA）。然而，由于先前未定义基准，因此定义这些患者的临床显著改善具有挑战性。我们的目的是定义 rTSA 翻修后，在术后结局评分和活动范围（ROM）方面的最小临床重要差异（MCID）、实质性临床获益（SCB）和患者可接受的症状状态（PASS），并量化达到临床相关成功的患者比例。
本回顾性队列研究使用了一家机构前瞻性收集的数据库，纳入了 2015 年 8 月至 2019 年 12 月期间接受初次 rTSA 翻修的患者。排除诊断为假体周围骨折或感染的患者。结局评分包括 ASES、原始和标准化 Constant、SPADI、SST 和加利福尼亚大学洛杉矶分校（UCLA）评分。ROM 测量包括外展、前向抬高（FE）、外旋（ER）和内旋（IR）评分。采用锚定和分布两种方法来计算 MCID、SCB 和 PASS。评估达到每个阈值的患者比例。
共评估了 93 例初次 rTSA 翻修患者，随访时间至少 2 年。平均年龄为 67 岁，56%为女性，平均随访时间为 54 个月。rTSA 翻修最常见的原因是解剖 TSA 失败（n=47），其次是半髋关节置换术（n=21）、rTSA（n=15）和表面置换术（n=10）。rTSA 翻修的主要指征是肩盂松动（n=24），其次是肩袖失败（n=23）、半脱位和不明原因疼痛（n=11）。基于锚定的 MCID 阈值（达到的患者比例）如下：ASES，20.1%（42%）；标准化 Constant，12.6%（80%）；UCLA，10.2%（54%）；SST，0.9%（78%）；SPADI，-18.4%（58%）；外展，13°（83%）；FE，18°（82%）；ER，4°（49%）；IR，0.8%（34%）。SCB 阈值（达到的患者比例）如下：ASES，34.1%（25%）；标准化 Constant，26.6%（43%）；UCLA，14.1%（28%）；SST，3.9%（48%）；SPADI，-36.4%（33%）；外展，20°（77%）；FE，28°（71%）；ER，15°（15%）；IR，1.0%（29%）。PASS 阈值（达到的患者比例）如下：ASES，63.5%（53%）；标准化 Constant，59.1%（61%）；UCLA，25.4%（48%）；SST，7.0%（55%）；SPADI，42.4%（59%）；外展，98°（61%）；FE，110°（56%）；ER，19°（73%）；IR，3.3%（59%）。
本研究确立了 rTSA 翻修后至少 2 年的 MCID、SCB 和 PASS 阈值，为医生提供了一种基于证据的方法，用于术后为患者提供咨询并评估患者的预后。
