Hao Kevin A, Hones Keegan M, O'Keefe Daniel S, Elwell Josie, Simovitch Ryan W, Wright Thomas W, King Joseph J, Schoch Bradley S
Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA.
Rothman Orthopaedics Florida at AdventHealth, Orlando, FL, USA.
Clin Orthop Relat Res. 2025 Mar 1;483(3):377-395. doi: 10.1097/CORR.0000000000003347. Epub 2025 Jan 7.
A variety of clinically important benchmarks of success (CIBS) have been defined for total shoulder arthroplasty (TSA) to quantify success. However, it is unclear how the preoperative status of the patient influences their likelihood of achieving each CIBS.
QUESTIONS/PURPOSES: (1) What proportion of patients achieve commonly used CIBS after TSA? (2) Is there a relationship between a patients' preoperative function and their probability of achieving different CIBS? (3) Does there exist preoperative ranges for each outcome measure that are associated with greater achievement of CIBS?
We retrospectively queried a multicenter shoulder arthroplasty database for primary anatomic TSA (aTSA) and reverse TSA (rTSA). A total of 2041 aTSAs and 3205 rTSAs were included. The mean ± SD age at time of surgery was 66 ± 9 years for aTSAs and 72 ± 8 years for rTSAs. In all, 51% (1049 of 2041) of aTSAs and 61% (1955 of 3205) of rTSAs were in patients who were women. For aTSAs, osteoarthritis with an intact rotator cuff was the most common preoperative diagnosis (92% [1869 of 2041]). For rTSAs, the most common preoperative diagnoses included rotator cuff tear arthropathy (40% [1280 of 3205]), osteoarthritis with an intact rotator cuff (24% [780 of 3205]), osteoarthritis with a torn rotator cuff (20% [632 of 3205]), and massive rotator cuff tear (10% [309 of 3205]). Outcomes were evaluated at latest follow-up (aTSA 61 ± 36 months, rTSA 47 ± 26 months) and consisted of ROM (abduction, forward elevation, external and internal rotation) as well as the most commonly used outcome scores: the Simple Shoulder Test (SST), Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California, Los Angeles (UCLA) score, Shoulder Pain and Disability Index (SPADI), and the Shoulder Arthroplasty Smart (SAS) score. The CIBS that we evaluated included the minimum clinically important difference (MCID), substantial clinical benefit (SCB), patient acceptable symptom state (PASS), minimum clinically important percentage of maximal possible improvement (MCI-%MPI), and substantial clinically important percentage of maximal possible improvement (SCI-%MPI). Prosthesis-specific anchor-based CIBS were adopted from prior publications on patients from this database. Multivariable regression was performed to identify the relationship between preoperative outcome measures and achievement of CIBS. Additionally, receiver operating characteristic (ROC) curve analyses were performed to determine whether thresholds in preoperative outcome measures were associated with achieving CIBS.
For all ROM measures and outcome scores, poorer preoperative ROM was associated with greater odds of achieving the MCID and SCB but lower odds of achieving the PASS. For the SST and the two scores without ceiling effects (the Constant and SAS scores), poorer preoperative outcome scores were associated with greater odds of achieving the MCI-%MPI and SCI-%MPI, but no association was demonstrated for the ASES, SPADI, and UCLA scores. Graphical analysis demonstrated that patients with greater preoperative ROM and outcome scores had a lower probability of achieving the MCID and SCB but a higher probability of achieving the PASS. For outcome scores with known ceiling effects, patients with more favorable preoperative outcome scores were more likely to achieve the MCI-%MPI and SCI-%MPI than the MCID and SCB, respectively. For outcome scores without ceiling effects, patients undergoing aTSA were more likely to achieve the MCID, MCI-%MPI, and the SCI-%MPI than the SCB, but no clear trend was identified for patients undergoing rTSA. On ROC curve analysis, identified thresholds were reasonably accurate (area under the curve > 0.7) for achievement of measures of absolute improvement (the MCID and SCB), but not for absolute postoperative status (the PASS) or relative improvement (the MCI-%MPI and SCI-%MPI).
While most patients reported being "much better" (aTSA 75%, rTSA 76%) or "better" (aTSA 15%, rTSA 18%) compared with before surgery, 10% of aTSAs and 6% of rTSAs were either "unchanged" or "worse." Patients' likelihood of achieving CIBS depends in part on their baseline function and whether success is defined as absolute improvement, absolute postoperative status, or relative improvement. Patients with more favorable preoperative status are more likely to achieve CIBS that evaluate relative improvement (the MCI-%MPI and SCI-%MPI) than absolute improvement (the MCID and SCB). Future studies are needed to determine which individual CIBS or combinations thereof most accurately represent clinically relevant benefit.
Level III, therapeutic study.
全肩关节置换术(TSA)已定义了多种临床重要的成功基准(CIBS)来量化手术的成功程度。然而,尚不清楚患者的术前状态如何影响其达到各项CIBS的可能性。
问题/目的:(1)TSA术后达到常用CIBS的患者比例是多少?(2)患者的术前功能与其实现不同CIBS的概率之间是否存在关联?(3)每种结局指标是否存在与更高CIBS达成率相关的术前范围?
我们回顾性查询了一个多中心肩关节置换术数据库,纳入了初次解剖型TSA(aTSA)和反置TSA(rTSA)的数据。共纳入2041例aTSA和3205例rTSA。aTSA手术时的平均年龄±标准差为66±9岁,rTSA为72±8岁。总体而言,aTSA的51%(2041例中的1049例)和rTSA的61%(3205例中的1955例)为女性患者。对于aTSA,术前最常见的诊断是伴有完整肩袖的骨关节炎(92%[2041例中的1869例])。对于rTSA,术前最常见的诊断包括肩袖撕裂性关节病(40%[3205例中的1280例])、伴有完整肩袖的骨关节炎(24%[3205例中的780例])、伴有撕裂肩袖的骨关节炎(20%[3205例中的632例])以及巨大肩袖撕裂(10%[3205例中的309例])。在最新随访时(aTSA为61±36个月/rTSA为47±26个月)评估结局,包括关节活动度(外展、前屈、外旋和内旋)以及最常用的结局评分:简易肩关节测试(SST)、Constant评分、美国肩肘外科医师学会(ASES)评分、加利福尼亚大学洛杉矶分校(UCLA)评分、肩痛与功能障碍指数(SPADI)以及肩关节置换智能(SAS)评分。我们评估的CIBS包括最小临床重要差异(MCID)、显著临床获益(SCB)、患者可接受症状状态(PASS)、最大可能改善的最小临床重要百分比(MCI-%MPI)以及最大可能改善的显著临床重要百分比(SCI-%MPI)。特定假体的基于锚定的CIBS采用自该数据库先前关于患者的出版物。进行多变量回归以确定术前结局指标与CIBS达成之间的关系。此外,进行了受试者工作特征(ROC)曲线分析,以确定术前结局指标的阈值是否与实现CIBS相关。
对于所有关节活动度测量指标和结局评分,术前关节活动度较差与达到MCID和SCB的几率较高相关,但达到PASS的几率较低。对于SST以及没有天花板效应的两个评分(Constant和SAS评分),术前结局评分较差与达到MCI-%MPI和SCI-%MPI的几率较高相关,但对于ASES、SPADI和UCLA评分未显示出相关性。图形分析表明,术前关节活动度和结局评分较高的患者达到MCID和SCB的概率较低,但达到PASS的概率较高。对于具有已知天花板效应的结局评分,术前结局评分更优的患者分别比达到MCID和SCB更有可能达到MCI-%MPI和SCI-%MPI。对于没有天花板效应的结局评分,接受aTSA的患者比达到SCB更有可能达到MCID、MCI-%MPI和SCI-%MPI,但对于接受rTSA的患者未发现明确趋势。在ROC曲线分析中,确定阈值对于实现绝对改善指标(MCID和SCB)具有合理的准确性(曲线下面积>0.7),但对于绝对术后状态(PASS)或相对改善(MCI-%MPI和SCI-%MPI)则不然。
虽然大多数患者报告与术前相比“好多了”(aTSA为75%,rTSA为76%)或“有所改善”(aTSA为15%,rTSA为18%),但10%的aTSA和6%的rTSA“无变化”或“更差”。患者实现CIBS的可能性部分取决于其基线功能,以及成功是定义为绝对改善、绝对术后状态还是相对改善。术前状态更优的患者比绝对改善(MCID和SCB)更有可能实现评估相对改善的CIBS(MCI-%MPI和SCI-%MPI)。未来需要进行研究以确定哪些个体CIBS或其组合最准确地代表临床相关获益。
III级,治疗性研究。