Sunday, July 16, 2017

How do we know if a shoulder joint replacement is effective?

Is the Simple Shoulder Test a valid outcome instrument for shoulder arthroplasty?

The Simple Shoulder Test (SST) is a brief, inexpensive, and widely used patient-reported outcome tool, but it has not been rigorously evaluated for patients having shoulder arthroplasty. These authors set out  to rigorously evaluate the validity of the SST for outcome assessment in shoulder arthroplasty using a systematic review of the literature and an analysis of its properties in a series of 408 surgical cases.

SST scores, 36-Item Short Form Health Survey scores, and satisfaction scores were collected preoperatively and 2 years postoperatively. Responsiveness was assessed by comparing preoperative and 2-year postoperative scores. Criterion validity was determined by correlating the SST with the 36-Item Short Form Health Survey. Construct validity was tested through 5 clinical hypotheses regarding satisfaction, comorbidities, insurance status, previous failed surgery, and narcotic use.

Scores after arthroplasty improved from 3.9 ± 2.8 to 10.2 ± 2.3 (P < .001). The change in SST correlated strongly with patient satisfaction (P < .001). The SST had large Cohen's d effect sizes and standardized response means. Criterion validity was supported by significant differences between satisfied and unsatisfied patients, those with more severe and less severe comorbidities, those with workers' compensation or Medicaid and other types of insurance, those with and without previous failed shoulder surgery, and those taking and those not taking narcotic pain medication before surgery (P < .005).

Based on theses data and a systematic review of the literature, these authors concluded that the SST is a valid and responsive patient-reported outcome measure for assessing the outcomes of shoulder arthroplasty.

Comment: More and more variations on shoulder arthroplasty are being introduced each year.

While the different types of shoulder arthroplasty are widely used for addressing glenohumeral pathology, an increasing number of questions are arising about it: 
(1) do new more expensive technologies (such as computer guidance, patient specific instrumentation, augmented glenoid components, metal backed glenoid components, pyrocarbcn humeral heads, short stem or stemless humeral components) yield long term clinical results that are superior to the standard total shoulder with a all polyethylene glenoid and stemmed humeral component inserted without guidance tools?
(2) which types of shoulder arthroplasty yield the best clinical outcomes for the different shoulder diagnoses in patients of different ages?
(3) how does surgeon case volume effect the clinical outcome for the patient?
(4) what patient characteristics are associated with poor clinical outcomes?
(5) are the clinical results of shoulder arthroplasty improving (see this link)?

These questions can only be answered using a practical and expensive valid patient-reported outcome tool that facilitates the collection of data from a large number of patients and practices. 

This study suggest that the 12 'yes' or 'no' questions of the Simple Shoulder Test provide such a tool.

The SST is used in almost a thousand publications and in over 6 languages. It is inexpensive, easy to score, easy for patients to understand, easy for patients to complete without needing to return to the provider's office, free from provider observer bias and valid.

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