What Specific Activities are Patients Performing Two Years After Primary Reverse Total Shoulder Arthroplasty?

Authors

Christopher M. Brusalis, MD, Alexander E. White, MD, Anthony Finocchiaro, BS, David M. Dines, MD, Joshua S. Dines, MD, Andreas Kontaxis, PhD, Samuel A. Taylor, MD, Lawrence V. Gulotta, MD, Michael C. Fu, MD, MHS

Journal

Seminars in Arthroplasty: JSES. 2023 February 3.

Abstract

Background

Returning patients to their usual activities following reverse total shoulder arthroplasty (RSA) is a critical component of achieving high patient satisfaction. As indications for RSA expand, patients’ desired and achieved activities remains inadequately characterized. We hypothesized that the vast majority of patients undergoing RSA returned to performing desired functional and recreational activities by two years postoperatively, with relatively lower rates of performing activities that involve internal rotation.

Methods

A shoulder arthroplasty registry at a tertiary care orthopedic hospital was reviewed retrospectively to identify specific patient activity capabilities at a minimum of two years postoperatively. Individual items within the American Shoulder and Elbow Surgeons (ASES) Shoulder Score and Shoulder Activity Scale (SAS) pertaining to activity levels were reviewed, including free text responses regarding usual work and usual sporting activity.

Results

The study cohort consisted of 238 patients (mean age = 71 ± 8 years, 61% female). Surgical indications consisted of osteoarthritis (69%, n = 164), and rotator cuff arthropathy (31%, n = 74). Median two-year postoperative ASES score for the operative extremity was 85 ± 18. Patients identified household chores (50%, n = 123), desk-related work (16%, n = 39), and heavy lifting activities (3%, n = 7) as the most common forms of usual work. Among 157 patients participating in sports at two years postoperatively, walking (27%, n = 42), golf (23%, n = 36), swimming (19%, n = 30), and weightlifting (15%, n = 24) were the most common sporting activities. At two-year follow-up, a high proportion of patients were able to comb their hair (90%, n = 215), manage toileting (89%, n = 213), and put on a coat (92%, n = 219). A relatively lower proportion of patients reported being able to lift ten pounds overhead (63%, n = 150) or wash their back (59%, n = 140).

Conclusion

Following RSA, patients exhibit a variety of desired functional and recreational activities. There persists a wide spectrum in patients’ capabilities to perform activities at two years postoperatively. The study findings may provide data to guide preoperative patient counseling.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS) in New York City (NYC) and New Jersey (NJ), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

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Development of Supervised Machine Learning Algorithms for Prediction of Satisfaction at Two Years Following Total Shoulder Arthroplasty

Authors

Evan M. Polce, BS, Kyle N. Kunze, MD, Michael Fu, MD, Grant E. Garrigues, MD, Brian Forsythe, MD, Gregory P. Nicholson, MD, Brian J. Cole, MD MBA, Nikhil N. Verma, MD

Journal

Journal of Shoulder and Elbow Surgery. 2020 Sep 30. DOI:https://doi.org/10.1016/j.jse.2020.09.007.

Abstract

Background

Patient satisfaction after primary anatomic and reverse total shoulder arthroplasty (TSA) represents an important metric for gauging patient perception of their care and surgical outcome. Although TSA confers improvement in pain and function for most patients, inevitably some will remain unsatisfied postoperatively. The purpose of the present study was to (1) train supervised machine learning (SML) algorithms to predict satisfaction after TSA and (2) develop a clinical tool for individualized assessment of patient-specific risk factors.

Methods

A retrospective review of primary anatomic and reverse TSA patients between January 2014 and February 2018 was performed. A total of 16 demographic, clinical, and patient-reported outcomes were evaluated for predictive value. Five SML algorithms underwent three iterations of 10-fold cross-validation on a training set (80% of cohort). Assessment by discrimination, calibration, Brier score, and decision curve analysis was performed on an independent testing set (remaining 20% of cohort). Global and local model behavior were evaluated with global variable importance plots and local interpretable model-agnostic explanation, respectively.

Results

The study cohort consisted of 413 patients, of which 331 (82.6%) were satisfied at two-years postoperatively. The support vector machine (SVM) model demonstrated the best relative performance on the independent testing set not used for model training (c-statistic=0.80, calibration intercept=0.20, calibration slope=2.32, Brier score=0.11). The most important factors for predicting satisfaction were baseline single assessment numeric evaluation (SANE) score, exercise and activity, workers compensation status, diagnosis, symptom duration prior to surgery, body mass index, age, smoking status, anatomic vs. reverse TSA, and diabetes. The SVM algorithm was incorporated into an open-access digital application for patient-level explanations of risk and predictions available here: https://orthopedics.shinyapps.io/SatisfactionTSA/

Conclusion

The best performing SML model demonstrated excellent discrimination and adequate calibration for predicting satisfaction following TSA and was used to create an open-access, clinical-decision making tool. However, rigorous external validation in different geographic locations and patient populations is essential prior to assessment of clinical utility. Given that this tool is based on partially modifiable risk factors it may enhance shared decision making and allow for periods of targeted, preoperative health optimization efforts.

Keywords

Total shoulder arthroplasty, satisfaction, classification, feature selection, cross-validation, supervised machine learning (SML), support vector machine (SVM)

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

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PROMIS Physical Function Underperforms Psychometrically Relative to American Shoulder and Elbow Surgeons Score in Patients Undergoing Anatomic Total Shoulder Arthroplasty

Authors

Michael C. Fu, MD, MHS, Brenda Chang, MS, MPH, Alexandra C. Wong, BS, Benedict U. Nwachukwu, MD, MBA, Russell F. Warren, MD, David M. Dines, MD, Joshua S. Dines, MD, Frank A. Cordasco, MD, MS, Stephen Lyman, PhD, Lawrence V. Gulotta, MD

Journal

Journal of Shoulder and Elbow Surgery. 2019 Sep;28(9):1809-1815.

Abstract

Background

The purpose of this study was to evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF-CAT) relative to the American Shoulder and Elbow Surgeons (ASES) score in patients with glenohumeral osteoarthritis undergoing primary anatomic total shoulder arthroplasty (TSA).

Methods

A retrospective study of an institutional TSA registry was performed. Preoperative PROMIS PF-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PF-CAT and ASES question items. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability.

Results

Responses from 179 patients (184 shoulders) were included. PF-CAT had a moderate correlation to ASES (r = 0.487; P < .001), with no floor or ceiling effects; ASES had a 1.1% floor effect and no ceiling effect. With iterative Rasch model item-reduction analysis eliminating poorly fitting question items, all possible PF-CAT items were eliminated after 6 iterations. With ASES, just 1 function question item was dropped. Person-item maps showed ASES to be superior to PROMIS PF-CAT psychometrically, with sequential and improved coverage of the latent dimension of shoulder disability.

Conclusion

Despite moderate correlation with ASES, PROMIS PF-CAT demonstrated inferior validity and psychometric properties in patients undergoing TSA. PF-CAT should not replace the ASES in this population of patients. KeywordsASES; PROMIS; arthroplasty; computer adaptive test; osteoarthritis; patient-reported outcomes; physical function; shoulder.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

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What Associations Exist Between Comorbidity Indices and Postoperative Adverse Events After Total Shoulder Arthroplasty?

Authors

Michael C. Fu, MD, MHS, Nathaniel T. Ondeck, MD, Benedict U. Nwachukwu, MD, MBA, Grant H. Garcia, MD, Lawrence V. Gulotta, MD, Nikhil N. Verma, MD, Jonathan N. Grauer, MD

Journal

Clinical Orthopaedics and Related Research. 2019 Apr; 477(4): 881–890.

Abstract

Background

Comorbidity indices like the modified Charlson Comorbidity Index (mCCI) and the modified Frailty Index (mFI) are commonly reported in large database outcomes research. It is unclear if they provide greater association and discriminative ability for postoperative adverse events after total shoulder arthroplasty (TSA) than simple variables.

Questions/Purposes

Using a large research database to examine postoperative adverse events after anatomic and reverse TSA, we asked: (1) Which demographic/anthropometric variable among age, sex, and body mass index (BMI) has the best discriminative ability as measured by receiver operating characteristics (ROC)? (2) Which comorbidity index, among the American Society of Anesthesiologists (ASA) classification, the mCCI, or the mFI, has the best ROC? (3) Does a combination of a demographic/anthropometric variable and a comorbidity index provide better ROC than either variable alone?

Methods

Patients who underwent TSA from 2005 to 2015 were identified from the National Surgical Quality Improvement Program (NSQIP). This multicenter database with representative samples from more than 600 hospitals in the United States was chosen for its prospectively collected data and documented superiority over administrative databases. Of an initial 10,597 cases identified, 70 were excluded due to missing age, sex, height, weight, or being younger than 18 years of age, leaving a total of 10,527 patients in the study. Demographics, medical comorbidities, and ASA scores were collected, while BMI, mCCI and mFI were calculated for each patient. Though all required data variables were found in the NSQIP, the completeness of data elements was not determined in this study, and missing data were treated as being the null condition. Thirty-day outcomes included postoperative severe adverse events, any adverse events, extended length of stay (LOS, defined as > 3 days), and discharge to a higher level of care. ROC analysis was performed for each variable and outcome, by plotting its sensitivity against one minus the specificity. The area under the curve (AUC) was used as a measure of model discriminative ability, ranging from 0 to 1, where 1 represents a perfectly accurate test, and 0.5 indicates a test that is no better than chance.

Results

Among demographic/anthropometric variables, age had a higher AUC (0.587–0.727) than sex (0.520–0.628) and BMI (0.492–0.546) for all study outcomes (all p < 0.050), while ASA (0.580–0.630) and mFI (0.568–0.622) had higher AUCs than mCCI (0.532–0.570) among comorbidity indices (all p < 0.050). A combination of age and ASA had higher AUCs (0.608–0.752) than age or ASA alone for any adverse event, extended LOS, and discharge to higher level of care (all p < 0.05). Notably, for nearly all variables and outcomes, the AUCs showed fair or moderate discriminative ability at best.

Conclusion

Despite the use of existing comorbidity indices adapted to large databases such as the NSQIP, they provide no greater association with adverse events after TSA than simple variables such as age and ASA status, which have only fair associations themselves. Based on database-specific coding patterns, the development of database- or NSQIP-specific indices may improve their ability to provide preoperative risk stratification.

Level of Evidence

Level III, diagnostic study.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

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Continued Inpatient Care After Primary Total Shoulder Arthroplasty Is Associated With Increased Short-term Postdischarge Morbidity: A Propensity Score–Adjusted Analysis

Authors

John M. Apostolakos, MD, MPH, Venkat Boddapati, MD, Michael C. Fu, MD, MHS, Brandon J. Erickson, MD, David M. Dines, MD, Lawrence V. Gulotta, MD, Joshua S. Dines, MD

Journal

Orthopedics. 2019 Mar 1;42(2):e225-e231.

Abstract

Advances in surgical technique and implant design during the past several decades have resulted in annual increases in shoulder arthroplasty procedures performed in the United States. The purpose of this investigation was to use the National Surgical Quality Improvement Program database to analyze the rates of morbidity following shoulder arthroplasty. The authors hypothesized that, independent of predischarge patient factors, discharge to inpatient facilities is associated with increased short-term morbidity. Patient demographics, intraoperative variables, and information about postoperative complications/readmissions up to 30 days after the operative event were collected from the National Surgical Quality Improvement Program database for the period 2005 to 2015. Patients were divided into 2 cohorts based on discharge to home vs non-home facilities. Unadjusted baseline patient characteristics were compared using Pearson's chi-square test, and a propensity score–adjusted comparison was also performed. Overall, 9058 patients were included. Of these, 7996 (88.3%) were discharged to home and 1062 (11.7%) were discharged to a non-home facility. On propensity-adjusted analysis, complications determined to be statistically significantly associated with non-home discharge included cardiac (odds ratio, 4.19; 95% confidence interval, 1.75–10.04; P=.001), respiratory (odds ratio, 2.63; 95% confidence interval, 1.47–4.70; P=.001), urinary tract infection (odds ratio, 2.66; 95% confidence interval, 1.52–4.67; P=.001), and death (odds ratio, 7.51; 95% confidence interval, 2.42–23.27; P<.001). Overall, complications were statistically significantly associated with non-home discharges (odds ratio, 2.05; 95% confidence interval, 1.59–2.64; propensity-adjusted P<.001). This investigation indicated an association between postdischarge placement into non-home facilities and an increase in short-term morbidity, regardless of preoperative patient comorbidities.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

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Surgical Anatomy of the Radial Nerve in the Deltopectoral Approach for Revision Shoulder Arthroplasty and Periprosthetic Fracture Fixation: A Cadaveric Study

Authors

Michael C. Fu, MD, MHS, Michael D. Hendel, MD, PhD, Xiang Chen, MS, Russell F. Warren, MD, David M. Dines, MD, Lawrence V. Gulotta, MD

Journal

Journal of Shoulder and Elbow Surgery, 2017-12-01, Volume 26, Issue 12, Pages 2173-2176

Abstract

Background

Radial nerve injury is a rare but clinically significant complication of revision shoulder arthroplasty and fixation of native and periprosthetic proximal humeral fractures. Understanding of the anatomic relationship between the radial nerve as it enters the humeral spiral groove and anterior shoulder landmarks in a deltopectoral approach is necessary to avoid iatrogenic radial nerve injury.

Methods

Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. Distances between the radial nerve entry into the proximal spiral groove and the coracoid process, distal lesser tuberosity/inferior subscapularis insertion, superior latissimus insertion, and inferior latissimus insertion were measured. Means, standard deviations, and ranges were determined for each distance.

Results

The radial nerve entry into the proximal spiral groove averaged 133.1 mm (range, 110.3-153.0 mm) from the coracoid process, 101.9 mm (range, 76.5-124.3 mm) from the distal lesser tuberosity/inferior subscapularis insertion, 81.0 mm (range, 63.4-101.5 mm) from the superior latissimus insertion, and 39.6 mm (range, 25.5-55.4 mm) from the inferior latissimus insertion. The proximal spiral groove was distal to the inferior latissimus insertion in all specimens.

Conclusion

The risk of iatrogenic injury to the radial nerve at the spiral groove may be minimized through proper identification and protection or avoidance of circumferential fixation. However, if encircling fixation with cerclage cables is necessary, instrumentation proximal to the inferior edge of the latissimus dorsi insertion may reduce the risk of radial nerve injury.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

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