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Revision shoulder arthroplasty: Patient-reported outcomes vary according to the etiology of revision
∗Corresponding author: Mandeep Virk. Mandeep.Virk@nyumc.org
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
The study evaluates patient-reported outcomes in revision shoulder arthroplasty (RevSA) according to etiology.
Twenty-three consecutive RevSA (minimum 2-year follow-up) were retrospectively reviewed. Patient-reported outcome (PRO) scores and range of motion were compared by the type of revision procedure and indication.
EQ5D-QOL, VAS-pain, ASES, and forward elevation improved after RevSA. The infection group had least improvements. Revision to a reverse total shoulder arthroplasty (RTSA) demonstrated the most improvement in VAS-pain, forward elevation, and ASES.
Revision to RTSA significantly improved PRO scores compared to hemi- or total shoulder arthroplasty. RevSA for infection demonstrated the least improvement in outcomes.
Keywords
Revision shoulder arthroplasty
Reverse shoulder arthroplasty
Patient-reported outcomes
Infection
Rotator cuff tear
Total shoulder arthroplasty
1 Introduction
Shoulder arthroplasty (SA) is an effective procedure in providing pain relief and functional improvement.1,2 Long-term studies have demonstrated excellent survivorship with primary shoulder arthroplasty with revision rates occurring as high as 13%.3 With the increasingly aging population and increase in number of primary arthroplasties, a higher prevalence of revision SA has resulted.4
Failure of primary shoulder arthroplasty can result from multiple causes including rotator cuff failure, component loosening, instability, and infection– all of which can present substantial challenges when performing a revision procedure.5,6 Previous studies have demonstrated worse outcomes and higher complication rates with revision SA when compared to primary arthroplasty.7,8 Certain risk factors including male sex, younger age, smoking, obesity, and poor surgical technique have been identified as significant predictors for poorer outcomes and subsequent revision procedures following primary arthroplasty.3,5 However, few studies have identified the influence of etiology and type of revision procedure on outcomes of revision SA. Thus, the purpose of this study is to evaluate how the different indications and type of revision implant impacts postoperative outcomes after revision SA. The study will specifically compare these outcomes using patient reported outcomes (PRO) scores and clinical assessments.
2 Materials and methods
Following approval from the Institution's Review Board (IRB), all consecutive revision SA procedures performed at our institution between August 2012 and November 2014 were retrospectively reviewed. Revision SA was defined as any procedure in which either the glenoid or humeral component was replaced, and included revision to hemi-arthroplasty (HA), total shoulder arthroplasty (TSA), and reverse total shoulder arthroplasty (RTSA). Patients who underwent a subsequent procedure to the ipsilateral shoulder within 2 years of the shoulder revision were excluded.
The authors have no competing interests to declare.
2.1 Data collection
This is a retrospective cohort study. Patients with a minimum follow-up of 2 years following their procedure were included. Electronic medical records were reviewed to collect patient baseline characteristics including age, gender, BMI, American Society of Anesthesiologist (ASA) scores, and index procedure. Clinical assessments as measured by PRO scores and range of motion (ROM) measurements (external rotation [ER] and forward elevation [FE]) were collected from preoperative and postoperative clinic notes. Four PROs that were collected prospectively were evaluated including EuroQol-5D (EQ-5D) scores,9 a measure of quality of life, American Shoulder and Elbow Surgeons (ASES) score,10 as well as visual analog scale (VAS) scores for pain and quality of life.
For the sub group analysis patients were grouped into four cohorts based on the indication for the revision SA including infection (INF), rotator cuff deficiency (RCD), aseptic component loosening (ASL), and instability (INSTAB).
2.2 Statistical analysis
2.2.1 Patient baseline characteristics were summarized using standard descriptive
Summaries (e.g. means and standard deviations [SD] for continuous variables, and percentages for categorical variables) and stored using Excel software (Microsoft Corporation, Richmond WA, USA). Chi-squared tests were used to compare categorical baseline patient characteristics between the different cohorts. ANOVA testing was used to compare means of the PRO scores and ROM measurements between the four cohorts. A p-value of <0.05 was considered statistically significant. All statistical analyses were done using SPSS Statistics software (International Business Machine Corporation, IL, USA).
3 Results
A total of 44 patients who underwent revision shoulder arthroplasty were initially identified. Seven patients were excluded for having an ipsilateral shoulder procedure within 2 years of their latest revision procedure and 14 were excluded for not having adequate follow up information documented in their EMR. A total of 23 patients were included in the study – 10 (43.5%) INF patients, 4 (17.4%) RC patients, 7 (30.4%) ASL patients, and 2 (8.7%) INSTAB patients. The mean follow-up in the cohort was 35.5 months. In the INF group, 6 patients were treated with a single-stage procedure while 4 were treated using a two-stage. Five HA, 11 TS A, and 7 RTSA in the cohort were revised to RTSA (14; 60.9%), TSA (5; 21.7%), and Hemi (4; 17.4%).
The average age of the total cohort was 66 years (range 37–82 years). Thirteen (56.5%) females and 10 (43.5%) males were included in the study with an average BMI of 28.0 ( ±4.4) kg/m2 and an average ASA score of 2.4 ( ±0.6). No significant difference with respect to age, BMI, or ASA scores were found between the 4 cohorts, while a significantly lower prevalence of females (p = 0.02) was found in the INF cohort (Table 1). The average number of revisions per cohort and the time since index surgery are presented in Table 1.
| Demographics | INF (n = 10) | RC deficiency (n = 4) | ASL (n = 7) | INSTAB (n = 2) | p-value |
| Age, (SD) | 67.5 (9.4) | 64.6 (11.9) | 65.0 (13.7) | 65.9 (13.5) | 0.96 |
| Gender, F (%) | 2 (20) | 3 (75) | 6 (85.7) | 2 (100) | 0.02 |
| BMI | 29.5 (2.7) | 23.6 (3.7) | 28.0 (5.8) | 29.4 (1.4) | 0.13 |
| ASA | 0.45 | ||||
| 2 | 5 | 2 | 6 | 2 | |
| 3 | 3 | 2 | 1 | 0 | |
| 4 | 2 | 0 | 0 | 0 | |
| Average (SD) | 2.7 (0.8) | 2.5 (0.5) | 2.1 (0.4) | 2.0 (0) | |
| Avg# of revisions (SD) | 1.5 (0.7) | 1.3 (0.5) | 1.4 (0.8) | 1.0 (0) | 0.78 |
| Time since index surgery (months) (SD) | 38.7 (33.1) | 33.0 (22.1) | 56.5 (36.2) | 6.5 (8.2) | 0.27 |
In the entire cohort, EQ5D-QOL improved by 0.13 points (p = 0.04), VAS pain scores improved by 2 points (p = 0.01), ASES scores improved by 20.5 (p = 0.01), and FE improved by 37° (p < 0.01) after revision surgery (Table 2). Of note, a 1.4-point and 21-point improvement in VAS-pain score and ASES score, respectively, have been identified as a clinically significant improvement following shoulder arthroplasty.11 VAS-QOL improved by 2.9 points (p = 0.60) and external rotation improved by 13° (p = 0.07). When comparing the cohort by indications, no significant differences were demonstrated in PRO scores or ROM metrics. The INF group had the least improvements in outcome measures (Table 3). When comparing outcomes based on the type of revision surgery, revision to an RTSA cohort demonstrated significant improvements in VAS pain score (3.1 versus −1.0 and 1.0 points, p = 0.01), ASES score (p = 0.02), and FE (p = 0.03) compared to revision to TSA and HA cohort (Table 4). Higher improvements in EQ5D (p = 0.25) VAS-QOL (p = 0.26), and ER rotation (p = 0.94) were also observed in the revision to RTSA cohort compared to the revision to TSA and HA cohort, although the results did not reach statistical significance.
| Outcomes value | n | Preop score | Final follow- up score | Change in score | p-value |
| EQ5D | 23 | 0.63 | 0.76 | 0.13 | 0.04 |
| VAS - QOL | 23 | 67.3 | 70.1 | 2.9 | 0.60 |
| ASES | 23 | 39.6 | 60 | 20.5 | 0.01 |
| VAS - Pain | 23 | 6.1 | 4 | −2 | 0.01 |
| FE | 21 | 87 | 134 | 37 | <0.01 |
| ER | 21 | 18 | 31 | 13 | 0.07 |
| Outcome value | Change in variable (Preop to Final follow-up value) | ||||
| INF | RC deficiency | ASL | INSTAB | p-values | |
| EQ5D | 0.1 (0.6–0.7) | 0.2 (0.7–0.9) | 0.1 (0.6–0.7) | 0.1 (0.7–0.8) | 0.90 |
| VAS - QOL | −5.1 (71.5–66.4) | 9.5 (64.8–74.3) | 11.2 (56.7–67.9) | 0.5 (88.0–88.5) | 0.91 |
| ASES | 16.5 (39.2–55.7) | 18.9 (41.0–59.9) | 23.2 (37.7–60.9) | 34.0 (45.0–79.0) | 0.95 |
| VAS - Pain | −1.7 (6.1–4.4) | −2 (6.0–4.0) | −2.3 (6.3–4.0) | −3 (5.5–2.5) | 0.95 |
| FE | 22 (96–118) | 72 (65–137) | 56 (87–143) | 90 (80–170) | 0.09 |
| ER | 12 (13–25) | 18 (15–33) | 11 (22–33) | 25 (0–25) | 1.0 |
| Outcome value | Change in variable (Preop to final follow-up value) | |||
| RTSA | TSA | HA | p-value | |
| EQ5D | 0.2 (0.6–0.8) | 0.0 (0.8–0.8) | 0.1 (0.5–0.6) | 0.25 |
| VAS-QOL | 10.9 (70.6–81.5) | 8.0 (59.3–67.3) | −13.8 (62.6–48.8) | 0.26 |
| ASES | 33.7 (38.2–72.9) | 8.2 (45.8–53.9) | −11.8 (40.5–28.8) | 0.02 |
| VAS-Pain | −3.1 (6.2–3.1) | −1.0 (5.5–4.5) | 1.0 (6.3–7.3) | 0.01 |
| FE | 61 (74–135) | 9 (107–116) | 3 (97–100) | 0.03 |
| ER | 15 (15–30) | 7 (35–42) | 5 (17–22) | 0.94 |
We also analyzed our original cohort with 1- year outcomes (see appendix). Results demonstrated similar results to the 2-year follow-up cohort including improved PRO scores and ROM values for the total revision cohort, as well as the most improved outcomes among patients who underwent RSTA.
4 Discussion
Our study demonstrates that not all revision shoulder arthroplasties are the same with respect to patient reported outcomes. Infection as the etiology had worse outcomes compared to revision for other indications. Likewise, revision to reverse shoulder arthroplasty has better outcomes compared to revision to anatomic total shoulder arthroplasty or hemiarthroplasty. The study findings have important clinical implications. The result of this study, especially pertaining to outcomes for revision shoulder arthroplasty for infection etiology, is relevant information to share with patients in preoperative counseling prior to revision shoulder arthroplasty.
Prior studies have supported our findings with respect to the poor outcomes associated with an infectious etiology. In the current study, revision shoulder arthroplasty for infection demonstrated the least improvement in both PRO scores and ROM. A review by Nelson et al.12 studied the outcomes of various forms of treatment following an infected shoulder arthroplasty implant including incision and drainage with retained implant, resection arthroplasty, 1-stage revision, 2-stage revision, and antibiotic spacer placement. The study found that the Constant score, a measure of shoulder functionality, for all treatment modalities was <50. These relatively low Constant scores reflect the limitations associated with treating perioprosthetic joint infections with a revision shoulder arthroplasty procedure. A study by Sajadi et al.8 that investigated outcomes of shoulder arthroplasty revision based on indication also noted poorer outcomes in patients undergoing revisions due to infection. They showed that revisions based on glenoid erosion, loosening, or humeral loosening, had significantly better outcomes with respect to ROM, pain, function, and satisfaction scores compared to patients who had went onto failure due to infection, soft-tissue problems (including instability, rotator cuff deficiency or both), or pain. Contrasting results by previous studies have also been reported in the literature. For instance, Ortmaier et al.13 concluded that there were no significant differences with respect to pain scores based on the indication of the revision, which included rotator cuff insufficiency and pseudoparalysis, instability, infection, component loosening, and tuberosity resorption.
As in the current study, recent studies have reported that instability and infection were the most common etiologies leading to revision shoulder arthroplasties in their respective cohorts.7,14 Boileau et al.14 identified that 43% of their revisions for failed RTSA was due to instability. They also found that the implantation of a primary RTSA for previous surgery stands as a risk factor for revision RTSA, demonstrated by the 1/3 of patients' etiologies being previous failed arthroplasty. Previous studies by Wall et al.15 and Stephens et al.16 similarly found that increased failure rates were associated with revisions for a failed HA or TSA. Furthermore, the study reflected the high-risk nature of revision surgery for failed or complicated RTSA based on the 30% of patients who required further surgical interventions. The authors stated that these complications were a result of their underestimation and underdiagnosis of humeral bone loss and/or associated low-grade infection. Nevertheless, despite the potential increased risks of revision procedures, studies have consistently demonstrated improvements in short-term postoperative patient-reported and clinical measures than prior to the revision.7,14,16
Another major finding from the current study supports that revision to either TSA or HA results in outcomes that are not par compared to RTSA. With respect to range of motion, our results demonstrate a significant improvement (61°; p = 0.03) in forward elevation which is comparable to Kelly et al.’s17 study that found a similar improvement (64° of forward flexion) in 28 patients who underwent revision RTSA for failed arthroplasty due to rotator cuff insufficiency without glenoid bone loss. Furthermore, the current study showed that pain scores improved in the RTSA cohort compared to the TSA/HA cohorts, the latter showing clinically insignificant improvements in VAS pain scores from the pre-to postoperative stages based on the minimum of 1.2-point change needed to observe a clinically significant difference.11 Improved outcomes in the former group have been supported by findings of past studies.18,19,20,21 Postoperative pain scores of revision RTSA have been observed between the range of 1.7–3.5, and a range of improvement from the pre-to postoperative stages between 6.0 and 1.4 points.13,16,21–25 Among revision RTSA procedures in the current study, pain scores improved by a magnitude that fell within this range (3.1). Finally, the current study reported postoperative ASES scores of 72.9 for revision RTSA and a 33.7 overall improvement, which is comparable to the 56 to 72 range of scores found in the literature,17,26 and is considered a clinically significant improvement based on a 21-point minimum cutoff needed to detect a clinical meaningful difference.11
The study has several limitations. First, the study was limited by the inherent nature of its retrospective design. Second, the number of patients in cohort was small and subgroup analysis could be underpowered to show significant differences among different groups. Third, long term follow up is not available. Fourth, we did not have a control group of primary arthroplasty and relied on historical data for outcomes after primary total shoulder arthroplasty. Finally we did not evaluate other variables that can affect outcome of the revision shoulder surgery including humerus bone loss, revision of cemented components, and glenoid bone loss.
5 Conclusion
Revision shoulder arthroplasty for infection had the least improvements in PRO scores compared to revision for other indications. Furthermore revision to RTSA is associated with significantly improved PRO scores compared to revision to TSA or HA.
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