Ryan Simovitch, MD
Read complete study: Younger patients report similar activity levels to older patients after reverse total shoulder arthroplasty
The authors conducted a study to measure a subjective questionnaire that reported type of activities, range of motion, pain and strength. The authors looked at patients younger and older than 65 to determine if there was a difference in activity levels and what the functional differences were in these patient populations. They broke activity level down into low, medium and high demand.
The authors bring up a good point for surgeons to think about. Older patients are not necessarily inactive patients. The patient population at my practice in South Florida is older demographically, but those patients still enjoy golfing, swimming, lifting weights, cycling, hunting and other similar activities that place high stresses on shoulder implants.
In my practice, I tend to view physiological age as a more important indicator than chronological age because my experience confirms what the study has above has found. Continue reading
Howard Routman, DO
Read the complete study: Causes of poor postoperative improvement after reverse total shoulder arthroplasty
This study reviewed comorbidities and results for higher baseline American Shoulder and Elbow Surgeons (ASES) scores that are correlated with poor post-operative improvement. The study collected data from a total of 150 patients who underwent reverse total shoulder arthroplasty (rTSA) from 2007-2013. A minimum of two-year post-operative ASES scores were included, and poor post-op improvement was defined as a change of ASES score of less than 12 points. Out of the 150 patients, male gender, presence of an intact rotator cuff at the time of surgery, depression, a higher baseline ASES score and higher total number of medical comorbidities were associated with poor post-operative improvement after rTSA. Neither patient age, nor indication for surgery, was found to correlate with poor improvement after rTSA. In general, the study population was older, with an average age of 71.6 +/- 8.8, and the majority of patients were female.
It should be noted that as the number of rTSAs continues to grow rapidly—due to its success in improving pain and function in most patients—some patients fail to improve clinically. Interestingly, the article also mentioned that patient satisfaction is now frequently linked to hospital and physician reimbursements. This study emphasizes reasons for poor post-operative improvement throughout with baseline pulled from ASES scores and patient data. Physical examination findings were not a focused component of the analysis.
The temptation to view the rTSA as a panacea that can fix everything is high. We need to temper our enthusiasm and ensure that we select our patients wisely.
When managing expectations with higher pre-operative ASES scores, I don’t really look at an ASES score pre-operatively as a screening tool, but I appreciate the concept of the ‘delta’ of improvement before surgery. If a patient’s radiograph shows a classic cuff tear arthropathy, and the patient has maintained overhead elevation and mild pain, the change in function and pain that can be provided with a perfect reverse is minimal. Ideally, patient selection can help us identify who best benefits from rTSA. By limiting the indications to patients who cannot elevate beyond 90⁰, and who identify themselves has having quality-of-life-altering pain, we can skew our delta favorably. The article referenced a study by Wall et al that noted patients who underwent rTSA for primary osteoarthritis had much smaller improvements in range of motion compared with patients who underwent rTSA for rotator cuff tear arthropathy or massive tears. Current expectations for improving post-operative function versus outcomes in patients with high levels of pre-operative function are to be noted.
In a cohort of 31 of my rTSA patients, the average post op ASES score was 82.68 (+/- 18.4), compared to 76 +/- 16.7 as mentioned in the study. Continue reading