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Preoperative patient-reported outcome measures (PROMs) have been shown to influence outcomes after total shoulder arthroplasty (TSA), although little is known about this relationship. An institutional shoulder arthroplasty registry was retrospectively queried for preoperative and 2-year postoperative 12-Item Short Form Health Survey (SF-12) and American Shoulder and Elbow Surgeons (ASES) scores for patients who underwent anatomic TSA (aTSA) or reverse TSA (rTSA). Preoperative PROMs were evaluated for their effect on patient achievement of minimal clinically important improvement (MCII) and substantial clinical benefit (SCB). In total, 451 aTSA patients and 93 rTSA patients had preoperative and 2-year follow-up scores. A total of 91.7% and 70.4% of patients achieved MCII and SCB at 2 years, respectively ( P <.001). Preoperative ASES scores were more predictive of achieving SCB than MCII (area under the curve [AUC], 0.83 vs 0.71). When accounting for mental and emotional health, the predictive ability of SF-12 physical component threshold values improved (AUC, 0.68). Preoperative threshold PROMs were found to accurately predict achievement of clinically significant outcomes at 2 years. Considering mental and emotional health improved the accuracy of these predictions. These data will assist surgeons and patients alike in setting expectations for outcomes after TSA. [ Orthopedics . 2021;44(4):e509-e514.].

Whether shoulder arthroplasty can be performed on an outpatient basis depends on appropriate patient selection. The purpose of this study was to identify risk factors for adverse events (AEs) following shoulder arthroplasty and to generate predictive models to improve patient selection. This was a retrospective review of prospectively collected data using a single institution shoulder arthroplasty registry as well as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including subjects undergoing hemiarthroplasty, total shoulder arthroplasty (TSA), and reverse TSA. Predicted probability of suitability for same-day discharge was calculated from multivariable logistic models for different patient subgroups based on age, comorbidities, and Charlson/Deyo Index scores. A total of 2314 shoulders (2079 subjects) in the institutional registry met inclusion criteria for this study. Younger age, higher body mass index (BMI), male sex, and prior steroid injection were all significantly associated with suitability for discharge, whereas preoperative narcotic use, comorbidities (heart disease and anemia/other blood disease), and Charlson/Deyo Index score of 2 were associated with AEs that might prevent same-day discharge. Compared with TSA, reverse TSA was associated with less suitability for discharge ( P =.01). On querying the ACS-NSQIP database, 15,254 patients were identified. Female sex, BMI less than 35 kg/m 2 , American Society of Anesthesiologists class III/IV, preoperative anemia, functional dependence, low pre-operative albumin, and hemiarthroplasty were associated with unsuitability for discharge. Males 55 to 59 years old with no comorbidities nor history of narcotic use formed the lowest risk subgroup. Transfusion is the primary driver of AEs. Strategies to avoid this complication should be explored. Risk stratification will improve the ability to identify patients who can safely undergo outpatient shoulder arthroplasty. [ Orthopedics . 2021;44(2):e215-e222.].

Background: The purpose of this study was to determine patients' preoperative expectations before primary elective reverse shoulder arthroplasty (RSA). We hypothesized that younger patients, patients with better preoperative function, patients with shoulder osteoarthritis (OA), and patients with no prior joint replacements would have higher expectations of RSA., Methods: We prospectively studied 333 primary RSAs performed for cuff tear arthropathy (n = 242), OA (n = 68), or post-traumatic arthritis (n = 23). Expectations were assessed preoperatively using the Hospital for Special Surgery's shoulder surgery expectations survey. Preoperative patient-reported measures were assessed with the American Shoulder and Elbow Surgeons shoulder score; Shoulder Activity Scale score; Short Form 12 mental component and physical component scores; and visual analog scale scores for pain, fatigue, and general health. A Poisson regression model was performed to control for potential confounding variables., Results: Relief of night-time pain, relief of daytime pain, improvement in self-care, improvement in the ability to drive or put on a seat belt, and improvement in the ability to perform daily activities were reported as "very important" by approximately half of patients. No association was found between age and overall expectations. Multivariate analysis showed that better preoperative Shoulder Activity Scale and Short Form 12 physical component scores were associated with greater expectations (P < .001). OA was associated with greater expectations compared with cuff tear arthropathy (P < .001). A history of either contralateral RSA or any joint replacement was associated with lower expectations (P < .001)., Conclusion: Patients have the highest expectations for pain relief and the performance of simple tasks after RSA. Patients with higher preoperative function, OA, and no previous joint replacements have greater expectations of RSA., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to determine the effect of preoperative expectations on outcomes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations would have better outcomes., Methods: Patients undergoing primary RSA completed the Hospital for Special Surgery's Shoulder Expectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoulder Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs). Pearson correlations were used to assess the relationship between the number of expectations and outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation question were assessed by independent samples t test. Multivariable linear regression analysis was used to control for potential confounding factors., Results: We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for relieving pain, improving self-care, improving ability to perform daily activities, and improving ability to drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving nighttime pain was associated with ASES (β = 7.0, P = .048) and VAS pain scores (β = -5.9, P = .047) as well as 2-year improvement of VAS pain (β = -6.1, P = .039). Higher expectations for improving the ability to participate in nonoverhead sports was associated with improvements in SAS (β = 2.8, P = .020)., Conclusion: A higher level of expectations for relief of nighttime pain and improving ability to participate in nonoverhead sports is associated with improved outcomes after RSA., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Although anatomic total shoulder arthroplasty (TSA) successfully improves pain and function, not all patients improve clinically. This study was conducted to determine patient-related factors for failure to achieve improvement after primary TSA for osteoarthritis at 2 years postoperatively., Methods: This prospective study reviewed an institutional shoulder registry for consecutive patients who underwent primary TSA for osteoarthritis from 2007 to 2013 with baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form scores. A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure, or both. Univariate and multivariable analyses of clinical and demographic patient factors were performed using logistic regression., Results: Of 459 arthroplasties that met inclusion criteria, 411 were deemed successful by the aforementioned criteria, and 48 (10.5%) failed to achieve a desirable outcome. Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure (P < .001)., Conclusion: Previous shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: With increasing incidence and indications for shoulder arthroplasty, there is an increasing emphasis on the ability to return to sports. The main goal of this study was to determine the rate of return to sport after shoulder arthroplasty., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to perform this systematic review and meta-analysis. A search was performed on MEDLINE, Scopus, EMBASE, and the Cochrane Library. The quality of the included studies was evaluated according to the Methodological Index for Nonrandomized Studies checklist. The main judgement outcome was the rate of return to sports activity after shoulder arthroplasty and the level of play upon return (identical or higher/lower level)., Results: Thirteen studies were reviewed, including 944 patients (506 athletes), treated with shoulder arthroplasty at an average follow-up of 5.1 years (range, 0.5-12.6 years). The most common sports were swimming (n = 169), golf (n = 144), fitness sports (n = 71), and tennis (n = 63). The overall rate of return to sport was 85.1% (95% CI, 76.5-92.3%), including 72.3% (95% CI, 60.6-82.8%) returning to an equivalent or improved level of play, after 1-36 months. Patients undergoing anatomic total shoulder arthroplasty returned at a significantly higher rate (92.6%) compared to hemiarthroplasty (71.1%, p = 0.02) or reverse total shoulder arthroplasty (74.9%, p = 0.003)., Conclusion: Most patients are able to return to one or more sports following shoulder arthroplasty, with anatomic total shoulder arthroplasty having the highest rate of return., Level of Evidence: IV.

Background: Recent studies have found that depression is associated with increased pain and impairment following lower-extremity arthroplasty; however, this association has not been investigated for total shoulder arthroplasty. The objective of this study was to investigate the association between depression and patient-reported outcomes following total shoulder arthroplasty., Methods: A prospectively collected institutional registry was queried for consecutive patients who underwent total shoulder arthroplasty for osteoarthritis from 2007 to 2013 with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores. Revision procedures and total shoulder arthroplasty for diagnoses other than osteoarthritis were excluded. Patients with a preoperative diagnosis of depression (n = 88) formed the study cohort; control patients without a diagnosis of depression were matched to the study patients by age and sex in a 2:1 ratio (n = 176). Baseline characteristics and patient-reported outcome measures were compared between groups, as were minimum 2-year patient-reported outcomes and change in patient-reported outcomes. A multivariable regression was performed to investigate the independent effect of depression on improvement in ASES scores., Results: Except for the Short Form-12 Mental Component Summary (SF-12 MCS) scores, there were no significant differences (p > 0.05) in baseline characteristics between study patients and controls. There was a significant improvement in the ASES score for patients with depression (p < 0.0001) and controls (p < 0.0001). Patients with depression had significantly lower final ASES scores (p = 0.001) and less improvement in ASES scores (p = 0.001) and SF-12 Physical Component Summary scores (p = 0.006) as well as lower satisfaction levels at 2 years; however, the latter difference did not reach clinical importance. Depression (p = 0.018) was an independent predictor of less improvement in ASES scores., Conclusions: Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with a clinical diagnosis of depression from undergoing total shoulder arthroplasty., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The American Shoulder and Elbow Surgeons (ASES) questionnaire was developed to provide a standardized method for evaluating shoulder function. Previous studies have determined the clinical responsiveness of this outcome measure for heterogenous populations or patients with nonoperatively treated rotator cuff disease. Currently, to our knowledge, no studies exist that establish the clinically relevant change in the ASES score after shoulder arthroplasty., Questions/purposes: We asked: (1) What are the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the ASES score after primary and reverse shoulder arthroplasties? (2) Are the MCID and SCB for the ASES score different between primary and reverse shoulder arthroplasties? (3) What patient-related factors are associated with achieving the MCID and SCB after total shoulder arthroplasty and reverse shoulder arthroplasty?, Methods: A longitudinally maintained institutional shoulder arthroplasty registry was retrospectively queried for patients who underwent primary shoulder arthroplasty, including anatomic or reverse total shoulder arthroplasty from 2007 to 2013, with a minimum 2-year followup. Seven hundred ninety-four patients were identified and eligible; 304 of these patients did not have 2 years of followup or complete datasets, resulting in a study cohort of 490 patients (62% of the 794 potentially eligible). The MCID and SCB of the ASES score for these patients was calculated using an anchor-based method, using four different anchors measuring satisfaction with work, activities, overall, and activity from the SF-36. The MCID (anchored to somewhat satisfied) and SCB (very satisfied) of the ASES score were calculated for the entire cohort and stratified by arthroplasty type. Multivariate logistic regression of patient-related factors that influence the MCID and SCB achievement was performed., Results: The MCID for all patients combined ranged from 6.3 to 13.5; for the overall satisfaction anchor, the MCID was 13.5 ± 4.5 (95% CI, 4.8-22.3). The SCB for the overall cohort ranged from 12.0 to 36.6; for the overall satisfaction anchor, the SCB was 36.6 ± 3.8 (95% CI, 29.1-44.1). There were no differences in the MCID of the ASES score between anatomic and reverse shoulder arthroplasty for any of the anchors (p = 0.159-0.992) or the SCB for any of the anchors (p = 0.467-0.977). Combining anatomic and reverse shoulder arthroplasty in one group, higher preoperative ASES score (odds ratio [OR], 0.96; 95% CI, 0.94-0.98; p < 0.001), having a reverse shoulder arthroplasty (OR, 0.36; 95% CI, 0.16-0.85; p = 0.016), and having rheumatoid arthritis were independent predictors of not achieving an MCID for the ASES 2 years after surgery. Higher preoperative ASES score (OR, 0.91; 95% CI, 0.89-0.92; p < 0.001), a diagnosis of rotator cuff tear arthropathy (OR, 0.14; 95% CI, 0.07-0.30; p < 0.001), a diagnosis of back pain (OR, 0.42; 95% CI, 0.24-0.71); p = 0.002), and living alone (OR, 0.36; 95% CI, 0.19-0.69; p = 0.002) were all independent predictors of not achieving SCB after shoulder arthroplasty., Conclusions: Patients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. High preoperative function was associated with a decreased likelihood of achieving clinically important change after total shoulder arthroplasty., Level of Evidence: Level III, therapeutic study.