Comparison of Patients Undergoing Primary Shoulder Arthroplasty Before and After the Age of Fifty

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1 This is an enhance PDF from The Journal of Bone an Joint Surgery The PDF of the article you requeste follows this cover page. Comparison of Patients Unergoing Primary Shouler Arthroplasty Before an After the Age of Fifty Matthew D. Saltzman, Deana M. Mercer, Winston J. Warme, Alexaner L. Bertelsen an Freerick A. Matsen, III J Bone Joint Surg Am. 2010;92: oi: /jbjs.i This information is current as of October 31, 2010 Reprints an Permissions Publisher Information Click here to orer reprints or request permission to use material from this article, or locate the article citation on jbjs.org an click on the [Reprints an Permissions] link. The Journal of Bone an Joint Surgery 20 Pickering Street, Neeham, MA

2 42 COPYRIGHT Ó 2010 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Comparison of Patients Unergoing Primary Shouler Arthroplasty Before an After the Age of Fifty By Matthew D. Saltzman, MD, Deana M. Mercer, MD, Winston J. Warme, MD, Alexaner L. Bertelsen, PAC, an Freerick A. Matsen III, MD Investigation performe at the Department of Orthopeics an Sports Meicine, University of Washington Meical Center, Seattle, Washington Backgroun: The reporte outcomes of shouler arthroplasty in patients uner the age of fifty years are worse than those in patients over fifty. While there are several possible explanations for this fining, we explore the possibility that patients who ha a primary shouler arthroplasty when they were uner fifty years of age iffere from those who ha the proceure when they were over fifty with respect to their pre-arthroplasty self-assesse comfort an function, sex istribution, an specific type of arthritis. Methos: The stuy group consiste of patients with glenohumeral arthritis who were treate with a primary shouler arthroplasty by the same surgeon between 1990 an For each ecae of age, the sex istribution, the prearthroplasty self-assesse shouler comfort an function, an the prevalence of twelve ifferent iagnoses were ocumente. We reviewe the series for three potential causes of worse outcomes in patients uner fifty years of age as compare with those over fifty years of age: (1) a higher percentage of women, (2) a lower score for pre-arthroplasty selfassesse comfort an function, an (3) more complex pathological conitions. Results: Patients uner the age of fifty years were not more likely than those over fifty to be female or to have a lower prearthroplasty self-assesse comfort an function score, but they i have more complex pathological conitions, such as capsulorrhaphy arthropathy, rheumatoi arthritis, an posttraumatic arthritis. Only 21% of the younger patients ha primary egenerative joint isease, whereas 66% of the oler patients ha that iagnosis. This ifference was significant (p < ). Conclusions: Surgeons performing shouler arthroplasty in iniviuals uner the age of fifty shoul be prepare to encounter pathological conitions such as capsulorrhaphy arthropathy, rheumatoi arthritis, an posttraumatic arthritis rather than primary osteoarthritis, which is more common in iniviuals oler than fifty. The pathoanatomy in these younger patients may complicate the surgery, the rehabilitation, an the outcome of the shouler arthroplasty. Shouler arthroplasty is most commonly performe for glenohumeral osteoarthritis in iniviuals over the age of sixty years 1-3. Historically, <10% of shouler arthroplasties have been performe in iniviuals uner the age of fifty 4.The outcomes of shouler arthroplasty have been note to be worse than expecte for patients uner fifty years of age 5-7. While recently there have been aitional reports of shouler arthroplasty in younger iniviuals 8-11, a PubMe literature review on March 22, 2009, reveale no irect comparison of the characteristics of young patients unergoing shouler arthroplasty with those of oler patients unergoing this proceure. We were particularly intereste in comparing the sex istribution, preoperative self-assesse comfort an function, an istribution of preoperative iagnoses between the younger an oler age groups because it has been observe that these factors may affect the outcome of reconstructive surgery 5,10, Specifically, we reviewe the series for three potential causes of worse outcomes of shouler arthroplasty in iniviuals uner the age of fifty: (1) a higher percentage of women, (2) worse pre-arthroplasty self-assesse comfort an function, an (3) a higher prevalence of iagnoses that are more complex than straightforwar primary egenerative joint isease. Disclosure: The authors i not receive any outsie funing or grants in support of their research for or preparation of this work. Neither they nor a member of their immeiate families receive payments or other benefits or a commitment or agreement to provie such benefits from a commercial entity. J Bone Joint Surg Am. 2010;92:42-7 oi: /jbjs.i.00071

3 43 TABLE I Age an Sex Distribution by Diagnosis Diagnoses Women <50 Yr Men <50 Yr Women >50 Yr Men >50 Yr Total Capsulorrhaphy arthropathy Degenerative joint isease Posttraumatic arthritis Osteonecrosis Rheumatoi arthritis Other inflammatory arthritis Cuff tear arthropathy Postinfectious arthritis Glenoi ysplasia Instability arthritis Charcot arthropathy Giant cell tumor Total Materials an Methos One thousan an forty-five consecutive patients with glenohumeral arthritis who were treate with a primary shouler arthroplasty by the same surgeon (F.A.M. III) between 1990 an 2008 were initially inclue in the stuy group. The age, sex, results of the preoperative Simple Shouler Test (SST), an iagnosis were ocumente by the surgeon at the time of the surgical proceure an entere at that time into a atabase approve for clinical research by our human subjects committee. The SST self-assessment of shouler comfort an function is well establishe an has been use extensively in other stuies The necessary an sufficient criteria for the various iagnoses have been previously publishe an were consistently applie by the surgeon uring the perio of this investigation 17,25. The ecision to perform a shouler arthroplasty was mae jointly by the patient an surgeon after a etaile iscussion about the alternatives an risks of the proceure. A variety of arthroplasty proceures were use in this population, but the choice of proceure was not analyze because a correlation of the arthroplasty type with the outcome was not a purpose of this stuy. For each ecae of age, we assesse the prevalence of twelve ifferent iagnoses, the sex istribution, an the self-assesse shouler comfort an function prior to the primary shouler arthroplasty. Fifteen of the recors were incomplete, an the necessary ata coul not be etermine; these patients were exclue from the analysis. This left 1030 patients for analysis. Because five iagnoses (postinfectious arthritis, glenoi ysplasia, instability arthritis, Charcot arthropathy, an giant cell tumor) were recore for fewer than eight patients each, these patients (nineteen in total) were exclue from further analysis; six of these patients were uner fifty an thirteen were over fifty at the time of the operation. Because this investigation was not a clinical trial, it was not necessary to register it in a public trials registry. Statistical Analysis Chi-square analyses were use to evaluate ifferences in SST scores accoring to sex an ecae of age. The SST scores for male an female patients for each ecae of age were analyze with use of the unpaire t test with assumption of unequal variance. Significance was efine as p < Source of Funing No external funing was receive for this investigation. Results The istributions of iagnoses by age an by sex are shown in Table I. Seventeen percent of the patients were uner an 83% were over fifty years of age. Patients uner the age of fifty were not more likely to be female than those over fifty years of age. Thirty-eight percent of the patients uner fifty an 39% of those over fifty were female. This ifference was thought to be clinically irrelevant an thus no statistical analysis was performe. TABLE II Total SST Score by Decae an Sex* Decae Women Men P Value ± ± ± ± ± ± 2.7 < ± ± 2.8 < ± ± 2.8 < ± ± 2.8 < ± ± ± 0.5 *Values are given as the mean an the stanar eviation.

4 44 Fig. 1-A Fig. 1-B Distribution of eight iagnoses by age in patients uner fifty years of age (Fig. 1-A) an those over fifty years of age (Fig. 1-B). Minor Dx = minor iagnoses, incluing postinfectious arthritis, glenoi ysplasia, instability arthritis, Charcot arthropathy, an giant cell tumor; fewer than eight patients ha each of these iagnoses. The mean pre-arthroplasty self-assesse comfort an function (SST) score (an stanar eviation) for the patients uner fifty years of age (3.37 ± 2.66 points) was not worse than that for the patients over fifty years of age (3.15 ± 2.71 points) (Table II). Because this ifference was thought to be clinically irrelevant, no statistical analysis was performe. It is of note that the pre-arthroplasty SST scores for women were consistently lower than those for men in the same ecae of life. It is

5 45 also of note that the pre-arthroplasty SST scores for women an those for men were remarkably consistent across the age groups. Patients uner fifty years of age ha a higher prevalence of iagnoses that were more complex than straightforwar primary egenerative joint isease. Of the 172 patients uner fifty, 136 (79%) ha a iagnosis other than primary egenerative joint isease in comparison with 291 (34%) of the 858 patients over fifty (chi-square p < ) (Figs. 1-A an 1-B) (Table I). Discussion Shouler arthroplasty is most commonly use in iniviuals over the age of fifty years to treat primary glenohumeral osteoarthritis. The outcomes are generally goo from the perspective of both the patient an the surgeon Shouler arthroplasty is also use to manage estruction of the glenohumeral joint from a variety of causes in younger iniviuals. The reporte outcomes of shouler arthroplasty in younger iniviuals are inferior to those for their oler counterparts. Sperling et al. reviewe the results of seventy-eight Neer shouler hemiarthroplasties an thirty-six Neer total shouler arthroplasties performe in patients who were fifty years of age or younger 6. Sixty-two shoulers treate with a hemiarthroplasty an twenty-nine treate with a total shouler arthroplasty ha a complete preoperative evaluation an complete operative recors an ha been followe for a minimum of fifteen years or until revision, an they were inclue in the clinical analysis. While there was significant (p < ) longterm pain relief an improvement in active abuction an external rotation after these proceures, the results, assesse with use of the Neer rating system, were not goo. There were six excellent, nineteen satisfactory, an thirty-seven unsatisfactory results after the hemiarthroplasties an six excellent, nine satisfactory, an fourteen unsatisfactory results after the total shouler arthroplasties. The authors conclue that care shoul be taken, an alternative methos of treatment shoul be actively consiere, when either a hemiarthroplasty or a total shouler arthroplasty is offere to patients who are fifty years ol or less. Other articles have confirme the challenges of performing shouler arthroplasty on younger patients 5,10. Because surgeons will continue to be consulte by patients uner fifty who have glenohumeral arthritis, it is important to ientify factors that may contribute to suboptimal outcomes. Possible factors are that, in comparison with their oler counterparts, younger patients have (1) relatively greater impairment of shouler function before surgery; (2) a ifferent sex istribution, leaing to ifferent perceptions of outcome; (3) ifferent iagnoses, incluing more complex pathological conitions; (4) increase emans an activity that increase the risk of loosening an wear; (5) increase expectations, making them at greater risk for issatisfaction; an (6) increase longevity, enabling more problems to appear over time. Ientification of such factors woul enable the surgeon to have a more informe preoperative iscussion with a younger patient who is consiering arthroplasty. In this stuy, we explore the first three of these factors. It has been previously recognize that women ten to report lower levels of comfort an function than men for the same iagnoses 13,16,17,19,20. We reviewe our series of patients to etermine if more women than men were uner fifty years ol, as such a iscrepancy may contribute to the perception of a worse outcome. The proportion of women was essentially the same in the younger an oler age groups. Aitionally, we reviewe the possibility that iniviuals uner the age of fifty have greater self-assesse isability before surgery, which might preispose them to the occurrence of a worse outcome. However, the patients uner the age of fifty in our stuy i not have lower scores on the preoperative SST. We also reviewe the possibility that the iagnoses of iniviuals uner the age of fifty who unergo shouler arthroplasty inclue a greater number of pathological conitions, such as capsulorrhaphy arthropathy (arthritis that occurs following a previous surgical stabilization proceure), that are more ifficult to manage than straightforwar egenerative joint isease. Capsulorrhaphy arthropathy was the iagnosis for 34% of the patients uner fifty an only 6% of those in the oler group. Rheumatoi arthritis was the iagnosis for 10% of the patients uner fifty an only 6% of the oler patients. Posttraumatic arthritis was the iagnosis for 15% of the younger patients an only 5% of those who were oler. In contrast, only 21% of the younger patients ha primary egenerative joint isease, whereas 66% of the oler patients ha this iagnosis. More complex pathological conitions are likely to have greater abnormalities of soft tissue an bone that can make surgery more ifficult an compromise the outcome of shouler arthroplasty in iniviuals uner the age of fifty. While previous stuies have suggeste that an age of less than fifty years is a preictor of worse outcomes after shouler arthroplasty 5,6, the finings of the present stuy suggest that the preoperative iagnosis may be a more important factor. For example, an oler patient with capsulorrhaphy arthropathy may have a worse outcome than an oler iniviual with egenerative joint isease; however, the outcome may be similar to that of a younger iniviual with the same iagnosis. Future stuies shoul be performe to evaluate whether patients uner the age of fifty have lower outcome scores than their oler counterparts when preoperative iagnosis is controlle for. While the ata o not suggest that a ifference in sex istribution preisposes patients to inferior outcomes, the consistency of the ifference in the pre-arthroplasty selfassesse comfort an function between the women an men inicates that stratification by sex may still be important in clinical outcome stuies of shouler arthroplasty. These finings nee to be interprete in light of certain limitations. First, this series represents the experience of only one surgeon. Secon, we i not compare the outcomes of the shouler arthroplasty with the preoperative characteristics of the patient. Thir, this stuy i not aress all of the pre-

6 46 operative characteristics that may iffer between patients younger an oler than fifty years of age. Fourth, the patients in this stuy unerwent a variety of arthroplasty proceures selecte on the basis of our approach to share ecisionmaking; there may be ifferent inications an combinations of proceures in other practices. Despite these limitations, it is clear that there was a significant ifference in the istribution of iagnoses between the younger an oler patients in this population treate with primary shouler arthroplasty. However, the younger group i not have a higher prevalence of women or a lower preoperative score for self-assesse shouler comfort an function. In iscussing shouler arthroplasty with younger patients, surgeons shoul explain that more complex pathological conitions, such as capsulorrhaphy arthropathy, rheumatoi arthritis, an posttraumatic arthritis, may complicate the surgical proceure an compromise its effectiveness in comparison with the situation with primary egenerative joint isease, which is more commonly seen in oler iniviuals. It is possible that the preoperative iagnosis has at least as much influence on the outcome of the proceure as oes the age of the patient. In future stuies comparing the results of primary shouler arthroplasty between younger an oler iniviuals, it will be important to stratify patients accoring to iagnosis an sex as well as age. n Matthew D. Saltzman, MD Department of Orthopaeic Surgery, Northwestern University, 676 North Saint Clair, 13th floor, Chicago, IL aress: msaltzman@gmail.com Deana M. Mercer, MD Winston J. Warme, MD Alexaner L. Bertelsen, PAC Freerick A. 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