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The Journal of Bone and Joint Surgery 78:260-4 (1996)
© 1996 The Journal of Bone and Joint Surgery, Inc.

Early Effectiveness of Shoulder Arthroplasty for Patients Who Have Primary Glenohumeral Degenerative Joint Disease*{dagger}

FREDERICK A. MATSEN III, M.D.{dagger}, SEATTLE, WASHINGTON

Investigation performed at the Department of Orthopaedics, University of Washington Medical Center, Seattle


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Twenty-nine consecutive patients who met strict criteria for a diagnosis of primary glenohumeral degenerative joint disease completed standardized questionnaires regarding general health status as well as function of the shoulder before I performed a total glenohumeral arthroplasty. The patients completed the forms again at an average of ten months after the operation. Comparison of the preoperative and postoperative responses to the questions regarding health status demonstrated highly significant improvement in the patients' assessments of over-all bodily pain (p < 0.0001) and physical function (p < 0.0005) as well as significant improvement in role function (p < 0.05) and the anticipated change in general health status (p < 0.05). Concurrently, comparison of the responses to the questions regarding function of the shoulder indicated highly significant improvement in the ability of the patients to sleep on the side, to tuck in the back of a shirt, to place the hand behind the head, to toss overhand (p < 0.0001 for all), and to place one pound (0.5 kilogram) (p < 0.005) or eight pounds (3.6 kilograms) (p <0.0001) on a shelf at shoulder level. The comparison also revealed significant (p < 0.05) improvement in the ability of the patients to place a coin on a shelf, to carry twenty pounds (9.1 kilograms) at the side, to wash the back of the contralateral shoulder, and to do their usual work.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The goal of reconstructive orthopaedic procedures is to improve the patient's function and sense of well-being. It is important for those of us in the field of orthopaedics to establish practical methods with which a surgeon can demonstrate his or her individual effectiveness in achieving this goal. Standardized and validated self-assessment tools that allow patients to characterize the quality of life as well as physical function are now available. The use of these tools before and after treatment offers a practical way to demonstrate the effectiveness of treatment from the perspective of the patient.

The aim of the present, prospective study was to use these self-assessment tools to characterize the early effectiveness of my own program of total glenohumeral arthroplasty in the treatment of primary glenohumeral degenerative joint disease.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Since January 1992, I have asked all new patients who have sought treatment because of a problem involving the shoulder to complete two standardized self-assessment questionnaires: the SF-36 questionnaire, which is used to define the general health status of the patient16, and the Simple Shoulder Test (SST), which is used to define the function of the shoulder11,12. The results of these questionnaires serve as the basis for the evaluation of the effectiveness of treatment from the perspective of the patient.

The present series comprised twenty-nine consecutive patients in whom I performed a total glenohumeral arthroplasty in 1992 or 1993 because of primary glenohumeral degenerative joint disease. The strict criteria for this diagnosis included (1) no history of trauma, of a previous operation, or of another known cause of secondary degenerative joint disease in the shoulder in which the operation was to be performed, (2) limited glenohumeral motion, and (3) radiographs showing narrowing of the joint space, periarticular sclerosis, periarticular osteophytes, and the absence of features indicative of other causes of loss of the joint surface12. My technique of total glenohumeral arthroplasty for primary glenohumeral degenerative joint disease was described in detail previously12. The present series did not include patients with degenerative joint disease who were managed non-operatively; thus, there were no non-operative controls.

Twenty patients were male and nine were female. The average age (and standard deviation) of the patients at the time of the operation was 65 ± 13 years. Sixteen patients had retired from work by the time of the procedure; eight worked in jobs that were not physically demanding, such as executive, professor, supervisor, or veterinarian; and five worked in jobs that were physically demanding, such as farmer, electrician, or manual laborer.

Sixteen shoulders were on the right side, and thirteen were on the left. Sixteen shoulders were on the side of the dominant extremity.

In an attempt to make the research as cost-effective and simple as possible, all follow-up questionnaires were sent to the homes of the patients at the same time (the first week of January 1994). All patients completed the forms on the first mailing and returned them by the middle of February 1994; no telephone contact or other prompting was necessary. The average time from the arthroplasty to the completion of the follow-up questionnaires was 303 ± 164 days.

The SF-36 questionnaires were scored according to the system described by Ware et al.16, and the preoperative and postoperative results were compared with use of the Wilcoxon signed-rank test to determine which parameters regarding the general health status of the patient were significantly different after total glenohumeral arthroplasty. Preoperative and postoperative results from the Simple Shoulder Test were compared with use of the paired rank test to determine which parameters regarding function of the shoulder were significantly improved after the operation. In addition, correlation coefficients were calculated among the changes in each of the twenty-one parameters to determine the degree to which the parameters were independent of each other.

To ascertain whether the changes in the parameters were affected by the duration of follow-up, the Mann-Whitney U test was used to compare the results for the fourteen patients who had been followed for less than 300 days after the operation with those for the fifteen patients who had been followed for 300 days or more. Correlation coefficients that related the change in each parameter to the duration of follow-up also were determined. Finally, Spearman rank correlations also were carried out between the number of days after the operation and each of the parameters.

The data were entered into a standard database (FileMaker Pro; Claris, Santa Clara, California) running on a laptop computer (Macintosh PowerBook; Apple Computer, Cupertino, California) and were analyzed with standard statistical software (StatView II; Abacus Concepts, Berkeley, California).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
At an average of ten months after the total glenohumeral arthroplasty, most of the parameters regarding the general health status of the patient and the function of the shoulder were substantially improved. The Wilcoxon signed-rank test revealed significant improvement in the parameters of over-all bodily pain (p < 0.0001), physical function (p < 0.0005), physical role function (p < 0.05), emotional role function (p < 0.05), and anticipated change in general health status (p < 0.05) (Table I). Similarly, for ten of the twelve parameters regarding function of the shoulder, the percentage of patients who stated that they could perform the function was significantly greater postoperatively compared with preoperatively (p < 0.05) (Table II).


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  		TABLE I IMPROVEMENT IN GENERAL HEALTH STATUS AS REFLECTED ON THE SF-36 QUESTIONNAIRE

 

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  		TABLE II IMPROVEMENT IN FUNCTION OF THE SHOULDER AS REFLECTED ON THE SIMPLE SHOULDER TEST

 
There were no strong correlations among most of the twenty-one parameters, indicating that the parameters were relatively independent of each other (Table III). The highest correlation coefficients were observed for improvements in six pairs of parameters: mental health and energy/fatigue (r = 0.787), placing eight pounds (3.6 kilograms) on a shelf and washing the back of the contralateral shoulder (r = 0.592), placing a coin on a shelf and placing one pound (0.5 kilogram) on a shelf (r = 0.544), physical function and energy/fatigue (r = 0.540), tossing overhand and placing eight pounds (3.6 kilograms) on a shelf (r = 0.519), and placing a coin on a shelf and tucking in the back of a shirt (r = 0.514). The highest correlation between an increment in a parameter regarding the general health status of the patient and one regarding the function of the shoulder was that for physical role function and the ability to place the hand behind the head (r = 0.507).


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  		TABLE III CORRELATIONS AMONG THE CHANGES IN THE PARAMETERS REGARDING FUNCTION OF THE SHOULDER AND GENERAL HEALTH STATUS OF THE PATIENT AFTER SHOULDER ARTHROPLASTY*

 
With the numbers available, we could detect no significant difference (p < 0.05) in the improvement in the parameters regarding the general health status of the patient or the function of the shoulder between the two subsets of patients with different durations of follow-up (Tables I and II). The correlation coefficients between the duration of follow-up and each of the parameters were all less than 0.2. The Spearman rank-correlation rho value was less than 0.5 for all parameters except the ability to toss underhand, for which it was 0.6.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
A great deal of interest recently has been directed toward the over-all effectiveness of operative procedures, including total joint arthroplasty2-10,13-15,17. However, little attention has been focused on the effectiveness of individual surgeons in the application of these procedures. It is axiomatic that each surgeon needs to know the degree to which the operation that he or she has performed and the program of postoperative management that he or she has directed have improved the patient's health status and function. Practicing surgeons need an efficient way to collect information regarding their individual effectiveness and to present this information to prospective patients and to those who pay for health care. It is insufficient for a surgeon to observe that others have reported a procedure to be effective; the surgeon must demonstrate its effectiveness when he or she performs it. This precept is credited to Codman, a pioneering shoulder surgeon, who presented the End Result Idea, "which was merely the common-sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire `if not, why not?' with a view to preventing similar failures in future."1 The present study is consistent with this idea, except that the word "hospital" is replaced with the word "surgeon." In the final analysis, the surgeon is the method.

Traditional approaches to clinical research involve return visits, radiographs, physical therapy measurements, and statisticians. The expense of these factors, both to the patient and to the physician, can be enough to put such investigations out of the reach of an individual surgeon in private practice. Furthermore, these so-called objective measures do not assess what may be the most important determinant of the success of a procedure: the patient's subjective evaluation of the improvement in health status and function. Because self-assessment questionnaires can be completed by patients at home, their use in measuring effectiveness optimizes the chances that all patients in a defined category will be included.

The two questionnaires used in the present study were well accepted by my patients, who completed the forms independently and without difficulty or reluctance. Many patients were enthusiastic about being asked for their own assessments of their health status and function of the shoulder; some added letters with extended commentary regarding the beneficial effects that the operation had had on their lives. With a few exceptions, postoperative changes in the twenty-one parameters (the twelve parameters regarding function of the shoulder on the Simple Shoulder Test and the nine parameters regarding general health status on the SF-36 questionnaire) were independent of each other. This finding suggests that the number of questions could not have been reduced without loss of information.

In the determination of the value of a treatment to a group of patients, it is critical to measure the status of the patients both before and after treatment. Standardized diagnostic criteria, along with self-assessments of health status and function, provide a practical method of characterizing the patient before and after treatment. The effectiveness of an individual surgeon in the application of a defined procedure to a group of patients with a defined diagnosis is reflected by the difference in the status of the patients before and after treatment. This information allows the surgeon to communicate, in terms that the patient can understand, the usual preoperative status of individuals having a procedure and the expected results of the procedure as performed by that surgeon.

The data presented here indicate that, among a carefully defined group of patients who had primary glenohumeral degenerative joint disease, my program of total glenohumeral arthroplasty improved, within a relatively short time, both the function of the shoulder and the general health status of the patient. With the numbers available, the results for the patients who were followed for less than 300 days (average, 166 ± 77 days) were not significantly different (p < 0.05) from those of the patients who were followed for 300 days or more (average, 431 ± 108 days). The long-term benefits of total glenohumeral arthroplasty for primary glenohumeral degenerative joint disease remain to be documented with use of these tools.

The present study is one of the first to demonstrate significant changes in health status as reflected on standardized questionnaires after reconstruction of the shoulder. More importantly, it suggests a practical method with which a surgeon can demonstrate his or her own effectiveness.

The present study was carried out without the expense or inconvenience of return visits, research assistants, or specialized computer software. Thus, the method and tools are practical and generic; they can be extended without difficulty to the measurement of the effectiveness of other programs of operative and non-operative treatment.


   Footnotes
 
*Although the author has not received and will not receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other non-profit organization with which the author is associated. No funds were received in support of this study.

{dagger}Department of Orthopaedics, University of Washington Medical Center, 1959 N.E. Pacific, Seattle, Washington 98195.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Codman, E. A.: The Shoulder. Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa, pp. v-xi. Malabar, Florida, Robert E. Kreiger, 1984.
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  3. Gross, M.: A critique of the methodologies used in clinical studies of hip-joint arthroplasty published in the English-language orthopaedic literature. J. Bone and Joint Surg., 70-A: 1364-1371, Oct. 1988.[Abstract/Free Full Text]
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  8. Keller, R. B.: How outcomes research should be done. In The Shoulder: a Balance of Mobility and Stability, pp. 487-499. Rosemont, Illinois, The American Academy of Orthopaedic Surgeons, 1993.
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  11. Lippitt, S. B.; Harryman, D. T., II; and Matsen, F. A., III: A practical tool for evaluating function: the Simple Shoulder Test. In The Shoulder: a Balance of Mobility and Stability, pp. 501-518. Rosemont, Illinois, The American Academy of Orthopaedic Surgeons, 1993.
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