1. Functional Outcome After Total Shoulder Arthroplasty: Lawrence V. Gulotta, MD Sports Medicine and Shoulder Service Hospital for Special Surgery Can Perioperative Factors be Predictive?

2. I Lawrence V. Gulotta am a consultant for Biomet, Inc, Level of Evidence: IV

3. Background TSA 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

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

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

6. Methods Inclusion Prospective registry data 1°TSA for OA Baseline & 2 year data Exclusion Patients not captured Dx other than OA Revision case

7. Shoulder Arthroplasty Registry Prospective data collection –2007 - present (ongoing) –22 surgeons Enrollment –All patients undergoing shoulder arthroplasty at HSS Data Demographics Medical HIstory ASES Score Details of Procedure Complications ASES Satisfaction Complications ASES Satisfaction BaselineIntra-Op2 Year5 Year

8. Shoulder Arthroplasty Registry 1190 Patients Enrolled

9. Shoulder Arthroplasty Registry

10. Patient Factors Gender Age Diagnosis Side ASA status Heart disease Lung disease Diabetes Cuff status *whether or not they underwent reoperation

11. Preoperative X-rays Glenoid bone loss <5mm 5-10mm >10mm Humeral Head Sblx > 25% considered abnormal JBJS 2003;85:21-258

12. Postoperative X-rays Glenoid Version –Gerber’s α angle Humeral head height –Tuberosity in relation to head JSES 2003;12:493-6 Eur J Rad 2008;68:159-69 > 10 degrees considered poor>10mm considered “overstuffed”

13. 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;11:587-94 Arthritis Care and Research 2009;61:623-32

14. 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

15. 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

16. Results MeasurementTotal NPercentage Glenoid Erosion < 5mm12669% 5-10mm4324% >10mm127% HH Sblx Yes2011% no16389%  Preoperative Measurements

17. Results MeasurementAverageRange Prosthesis Height4.8 mm-3 to 12 mm Glenoid Version-6.9°-20 to 2°  Postoperative Measurements

18. Results Overall ASES Scores MeanSD Baseline 35.7217.32 2-year 85.5113.68 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

19. Results Good vs Poor ASES Scores > 50 (181)< 50 (8) MeanSDMeanSDp-value Baseline 38.9216.4424.5015.020.016 2-year 87.5112.7728.4612.90<0.001 Change 48.59203.9614.17<0.001 p-value (w/in group) <0.00010.573 Why did these patients do so poorly?

20. Analysis Crude95% CI Adjusted95% CI Variable ORLowerUpperORLowerUpperp-value Age at surgery1.090.991.20 1.110.961.290.050 Female sex3.460.6817.62--- Non-OA diagnosis3.860.4037.35--- Bilateral0.00 --- *Repeat surgery on the joint replaced*4.170.4439.44--- Cuff Repair Performed10.500.85130.16--- Heart disease5.110.7933.11--- Lung Disease7.001.2240.30 13.711.28147.260.031 Diabetes12.602.5562.25 11.971.01142.420.049 *PRE Glenoid erosion*0.440.073.03--- *PRE HH subluxation (+)*0.00 --- POST Abnormal humeral head height (outside 2-5mm)0.200.021.84--- *POST Overstuffed HH height (>10mm)*1.070.1110.52--- POST Abnormal glenoid version1.270.207.96--- *POST Glenoid version <-10 deg*0.870.0710.01---

21. 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

22. 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

23. 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

24. Strengths Prospective Registry data Multiple surgeons Patient & surgical factors assessed TSA only (hemi’s excluded) Validated Outcome Weaknesses Short-term

25. 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

26. Thank You