Are Age and Patient Gender Associated With Different Rates and Magnitudes of Clinical Improvement After Reverse Shoulder Arthroplasty?
Are Age and Patient Gender Associated With Different Rates and Magnitudes of Clinical Improvement After Reverse Shoulder Arthroplasty?
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DOI：
10.1007/s11999.0000000000000270
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发表时间：
2018-06-01
影响因子：
4.2
通讯作者：
Zuckerman, Joseph D.
中科院分区：
文献类型：
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作者：
Friedman, Richard J.;Cheung, Emilie V.;Zuckerman, Joseph D.
背景进一步了解性别差异和自然老化过程如何与反向全肩关节置换术（rTSA）后结局指标评分和ROM测量的临床改善差异相关，可能有助于医生建立更准确的患者预期，以减少术后疼痛和改善功能。性别是否与rTSA结局评分的差异相关，如简单肩关节测试（SST）、UCLA肩关节评分、美国肩肘外科医生（ASES）肩关节评分、Constant肩关节评分，肩关节疼痛和残疾指数（SPADI）和ROM？(2)年龄与rTSA结局评分和ROM的差异相关吗？(3)哪些因素与年龄和性别之间的综合交互作用有关？(4)在恢复期间的哪个时间点出现大多数临床改善，何时达到完全改善？方法对660例患者的治疗结果进行量化分析女性424例，男性236例，平均年龄72.8岁;范围，43 - 95岁）由来自纵向维护的国际数据库的13名肩关节外科医生使用线性混合效应统计模型对肩袖撕裂关节病或骨关节炎和肩袖撕裂进行rTSA治疗，以评价临床改善与性别和患者年龄。我们使用五个结果评分指标和四个ROM评估来评估临床结果差异。（平均差异[MD]= 1.41分[95%置信区间{CI}，1.07 - 1.75]，p <0.001），UCLA评分（MD = 1.76 [95% CI，1.05 - 2.47]，p <0.001），Constant评分（MD = 6.70 [95% CI，4.80 - 8.59]，p <0.001），ASES评分（MD = 7.58 [95% CI，5.27 - 9.89]，p <0.001），SPADI评分（MD =-12.78 [95% CI，-16.28至-9.28]，p <0.001），外展（MD = 5.79度[95% CI，2.74 - 8.84]，p <0.001），前屈（MD = 7.68度[95% CI，4.15 - 11.20]，p <0.001）和被动外旋（MD = 2.81度[95% CI，0.81 - 4.8]，p = 0.006）。当控制性别时，年龄每增加1岁，ASES评分改善0.19分（95% CI，0.04 - 0.34，p = 0.011），SPADI评分改善-0.29分（95% CI，-0.46至0.07，p = 0.020）。然而，年龄每增加1岁，主动外展平均减少0.26度（95% CI，-0.46至0.07，p = 0.007），前屈平均减少0.39度（95% CI，-0.61至0.16，p = 0.001）。仅在主动外旋中发现了年龄和性别之间的联合交互作用：在男性中，年龄较小与主动外旋较少相关，年龄较大与主动外旋较多相关（beta（0）[截距]= 11.029，beta（1）[年龄变量斜率]= 0.281，p = 0.009）。相反，无论手术时的年龄如何，rTSA后女性的主动外旋没有差异（β（0）[截距]= 34.135，β（1）[年龄变量的斜率]=-0.069，p = 0.009）。最后，80%的患者实现了完全临床改善（由结局指标评分的平台期定义），70%的患者实现了完全临床改善（由结局指标评分的平台期定义）。的患者在12个月随访时达到了完全的临床改善，定义为ROM测量的平台期，无论性别或手术时的患者年龄如何，大多数改善发生在rTSA后的前6个月。与rTSA结果的一些差异相关。男性的预后评分优于女性，老年患者的预后评分优于年轻患者，但功能改善较小。这些结果表明，男性和女性以及手术时不同年龄的患者的rTSA结局不同，了解这些差异以及结局指标评分和ROM测量的改善平台的时间可以提高患者咨询的有效性，并更好地建立rTSA后准确的患者期望。
Background An improved understanding of how gender differences and the natural aging process are associated with differences in clinical improvement in outcome metric scores and ROM measurements after reverse total shoulder arthroplasty (rTSA) may help physicians establish more accurate patient expectations for reducing postoperative pain and improving function.Questions/purposes (1) Is gender associated with differences in rTSA outcome scores like the Simple Shoulder Test (SST), the UCLA Shoulder score, the American Shoulder and Elbow Surgeons (ASES) Shoulder score, the Constant Shoulder score, and the Shoulder Pain and Disability Index (SPADI) and ROM? (2) Is age associated with differences in rTSA outcome scores and ROM? (3) What factors are associated with the combined interaction effect between age and gender? (4) At what time point during recovery does most clinical improvement occur, and when is full improvement reached?Methods We quantified and analyzed the outcomes of 660 patients (424 women and 236 men; average age, 72 8 years; range, 43-95 years) with cuff tear arthropathy or osteoarthritis and rotator cuff tear who were treated with rTSA by 13 shoulder surgeons from a longitudinally maintained international database using a linear mixed effects statistical model to evaluate the relationship between clinical improvements and gender and patient age. We used five outcome scoring metrics and four ROM assessments to evaluate clinical outcome differences.Results When controlling for age, men had better SST scores (mean difference [MD] = 1.41 points [95% confidence interval {CI}, 1.07-1.75], p < 0.001), UCLA scores (MD = 1.76 [95% CI, 1.05-2.47], p < 0.001), Constant scores (MD = 6.70 [95% CI, 4.80-8.59], p < 0.001), ASES scores (MD = 7.58 [95% CI, 5.27-9.89], p < 0.001), SPADI scores (MD = -12.78 [95% CI, -16.28 to -9.28], p < 0.001), abduction (MD = 5.79 degrees [95% CI, 2.74-8.84], p < 0.001), forward flexion (MD = 7.68 degrees [95% CI, 4.15-11.20], p < 0.001), and passive external rotation (MD = 2.81 degrees [95% CI, 0.81-4.8], p = 0.006). When controlling for gender, each 1-year increase in age was associated with an improved ASES score by 0.19 points (95% CI, 0.04-0.34, p = 0.011) and an improved SPADI score by -0.29 points (95% CI, -0.46 to 0.07, p = 0.020). However, each 1-year increase in age was associated with a mean decrease in active abduction by 0.26 degrees (95% CI, -0.46 to 0.07, p = 0.007) and a mean decrease of forward flexion by 0.39 degrees (95% CI, -0.61 to 0.16, p = 0.001). A combined interaction effect between age and gender was found only with active external rotation: in men, younger age was associated with less active external rotation and older age was associated with more active external rotation (beta(0) [intercept] = 11.029, beta(1) [slope for age variable] = 0.281, p = 0.009). Conversely, women achieved no difference in active external rotation after rTSA, regardless of age at the time of surgery (beta(0) [intercept] = 34.135, beta(1) [slope for age variable] = -0.069, p = 0.009). Finally, 80% of patients achieved full clinical improvement as defined by a plateau in their outcome metric score and 70% of patients achieved full clinical improvement as defined by a plateau in their ROM measurements by 12 months followup regardless of gender or patient age at the time of surgery with most improvement occurring in the first 6 months after rTSA.Conclusions Gender and patient age at the time of surgery were associated with some differences in rTSA outcomes. Men had better outcome scores than did women, and older patients had better outcome scores but smaller improvements in function than did younger patients. These results demonstrate rTSA outcomes differ for men and women and for different patient ages at the time of surgery, knowledge of these differences, and also the timing of improvement plateaus in outcome metric scores and ROM measurements can both improve the effectiveness of patient counseling and better establish accurate patient expectations after rTSA.