Psychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review

doi:10.1016/j.jse.2019.09.043

Journal of Shoulder and Elbow Surgery

Volume 29, Issue 5, May 2020, Pages e175-e184

https://doi.org/10.1016/j.jse.2019.09.043 Get rights and content

Background

Both anatomic and reverse total shoulder arthroplasty are considered successful surgeries to treat a variety of painful shoulder conditions. Although implant survivorship for both is good to excellent in the long term, a variety of factors—clinical, technical, and psychosocial—may affect patient-reported outcomes after shoulder arthroplasty.

Methods

A comprehensive review of the literature was performed systematically using keywords “shoulder arthroplasty outcomes,” “psychosocial factors shoulder,” “shoulder replacement outcomes,” “depression shoulder arthroplasty,” “satisfaction shoulder arthroplasty,” “factors shoulder replacement,” “expectations shoulder arthroplasty,” and “predictors shoulder arthroplasty.” Studies meeting the inclusion criteria were screened and analyzed. Type of surgery performed, sample size, outcome measures, and other factors influencing patient outcomes were recorded and analyzed.

Results

Sixteen studies met the inclusion criteria. Six reviewed mental health disorders as predictors of postoperative outcome after shoulder arthroplasty. Of these, 4 found that disorders such a depression and anxiety were associated with increased risk of perioperative complications and lower final functional outcome scores. Two studies evaluated workers' compensation status as a possible predictor of outcomes and found that patients with claims had lower satisfaction and outcome scores at final follow-up compared with those without claims. Two studies showed that preoperative opioid use was associated with lower outcome scores and overall satisfaction rate after shoulder arthroplasty. Three studies showed that higher patient confidence and preoperative expectations were correlated with better outcomes.

Conclusion

Our review shows that psychosocial factors may play just as important role in affecting patient outcomes after total shoulder arthroplasty as technical factors.

Section snippets

Search strategy

A comprehensive literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. One independent reviewer systematically searched the databases PubMed, Medline, Cochrane, Scopus, and Google Scholar. The following date range was used in the search engines: May 30, 2000, to May 30, 2019. The following combination of keywords was used for the search: “shoulder arthroplasty outcomes,” “psychosocial factors shoulder,” “shoulder

Study characteristics

There were 16 studies that met the inclusion criteria. Level of evidence, study design, clinical question answered, and average follow-up for each of the included studies are presented in Table I. The included studies looked at outcomes after revision and primary cases. The study population underwent either TSA or rTSA. Psychosocial factors influencing shoulder arthroplasty outcomes included preoperative opioid use, preoperative patient expectations, diagnosis of depression, anxiety, or other

Discussion

Our analysis reveals that pre-existing diagnosis of a mental health disorder, an active WC claim, and preoperative opioid use are correlated with lower patient-reported postoperative outcome scores after shoulder arthroplasty compared with unaffected controls.²⁵^,32, 33, 34^,⁵⁰^,⁵¹ These results are similar to outcome studies in hip and knee arthroplasty. Duivenvoorden et al¹² showed that patients with preoperative anxiety and depressive symptoms had worse patient-reported outcomes and less

Conclusion

Our review suggests that preoperative diagnosis of mental health disorders, WC status, preoperative opioid use, patients' expectations and confidence level, patients' resilience, health insurance status, and amount of manual labor required for work all affect patient-reported postoperative outcomes after TSA. Psychosocial factors may play just as important, if not more, a role in affecting patient outcomes after TSA as technical factors.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (41)

Psychiatric comorbidities are an independent risk factor for perioperative and postoperative complications in patients undergoing primary total shoulder arthroplasty
2024, Seminars in Arthroplasty JSES
Historically, the association between perioperative complications following general surgery and psychiatric comorbidities has been well established. However, in the ever-changing landscape of total shoulder arthroplasty (TSA) and the population suffering from mental health disorders, research investigating the most current trends on a population level is needed. The purpose of this study is to evaluate the influence a preoperative diagnosis of anxiety, depression, or psychosis has on adverse events, length of stay, and the medical and mechanical complications following TSA at 180 days.
The Nationwide Readmissions Database was queried, and 128,382 discharges having undergone a primary TSA between 2010 and 2019 were identified. Subjects were divided into a mental health diagnosis (MHD) and no MHD group. The MHD group was further stratified by the diagnosis of depression, anxiety, or psychosis. Logistic regression analysis was performed for each of the outcome variables.
Patients with any MHD were more likely to smoke, suffer from hypertension, and have a higher Charlson-Deyo index. Despite their higher rates of comorbidities, regression analysis revealed that any MHD was an independent predictor of any complication, any mechanical complication, and revision within 180 days ([odds ratio (OR) = 1.26, 95% confidence interval (CI) (1.18, 1.33), P < .001], [OR = 1.50, 95% CI (1.33, 1.67), P < .001], and [OR = 1.54, 95% CI (1.31, 1.64), P < .001, respectively]).
Patients undergoing primary TSA with a preoperative MHD are at increased risk of perioperative morbidity. Careful consideration for surgery, as well as discussion and increased postoperative surveillance should be considered in this at-risk population.
History of mood and anxiety disorders affects return to work and return to sports after rotator cuff repair
2024, Revue de Chirurgie Orthopedique et Traumatologique
Après réparation de la coiffe des rotateurs (RCR), la reprise du travail et du sport est influencée par différents facteurs psychosociaux, parmi lesquels le rôle des antécédents anxiodépressifs (AAD) est débattu. L’objectif principal de cette étude était d’étudier l’influence des AAD sur la reprise du travail et du sport après RCR. L’hypothèse de travail était que les délais de reprise du travail et du sport seraient allongés et les taux de reprises diminués en cas d’AAD.
Il s’agit d’une étude rétrospective monocentrique incluant des patients opérés d’une RCR arthroscopique (rupture distale du supraspinatus). Les patients ayant une activité professionnelle et ceux qui pratiquaient un sport en préopératoire ont été inclus respectivement dans un groupe « travail » et un groupe « sport ». Les critères d’évaluations principaux étaient les délais postopératoires de reprise du travail et du sport. Les critères d’évaluation secondaires étaient : les taux de reprise du travail et du sport à 3, 6, et 12 mois, le taux de retour au même niveau sportif, le changement ou l’arrêt du travail ou du sport. L’analyse de l’effet des antécédents anxiodépressifs sur ces différents critères d’évaluation a été réalisée avec des méthodes de statistiques bayésiennes, en analyses multivariées.
Le groupe « travail » comptait 158 patients (dont 16,5 % de patients avec des AAD) et le groupe « sport », 118 (dont 17,8 % de patients avec des AAD). En présence d’AAD, la reprise du travail se faisait en moyenne 21 ± 11 semaines et la reprise du sport 17 ± 8,2 semaines plus tard qu’en l’absence d’AAD. On retrouvait une probabilité de 98 % que la reprise du travail et du sport soit retardée d’au moins 4 semaines chez les patients avec AAD. Le risque que les patients avec des AAD arrêtent complètement le sport était 2,8 fois plus important (OR = 2,8 [1 ; 7,8]).
Nous retrouvons une influence négative des AAD sur les modalités de reprise du travail et du sport.
III ; étude rétrospective cas-témoins.
After rotator cuff repair (RCR), return to work and return to sports is affected by various psychosocial factors. The role of one of these factors — mood and anxiety disorders (MAD) — is still not clear. The primary objective of this study was to determine the influence of prior MAD on the return to work and return to sports after RCR. Our hypothesis was that patients with a history of MAD would take longer to return to work and to sports after RCR, and the rate of return would be lower, than for patients without MAD.
This was a retrospective single-center study of patients who underwent arthroscopic RCR (distal supraspinatus tear). Patients who were employed and those who participated in sports before the surgery were included in the “working” and “sports” groups, respectively. The primary outcomes were the time to return to work and return to sports after surgery. The secondary outcomes were the ratio of patients returning to work and to sports at 3, 6, and 12 months; rate of return to same level of sports; need to change or stop working or sports. The effects of prior MAD on these various outcomes were determined using Bayesian multivariate analysis.
The “working” group consisted of 158 patients (of which 16.5% had MAD) and the “sports” group consisted of 118 patients (of which 17.8% had MAD). In those with a history of MAD, return to work was 21 ± 11 weeks later and the return to sports was 17 ± 8 weeks later than in those without MAD. There was a 98% probability that return to work or return to sports was delayed by at least 4 weeks in patients with history of MAD. The likelihood that patients with prior MAD who undergo RCR will completely abandon their sport was 2.8 times higher (OR = 2.8 [1; 7.8]).
We found a negative influence of prior MAD on the return to work and return to sports after RCR.
III; retrospective case-control study.
History of mood and anxiety disorders affects return to work and return to sports after rotator cuff repair
2024, Orthopaedics and Traumatology: Surgery and Research
After rotator cuff repair (RCR), return to work and return to sports is affected by various psychosocial factors. The role of one of these factors – mood and anxiety disorders (MAD) – is still not clear. The primary objective of this study was to determine the influence of prior MAD on the return to work and return to sports after RCR. Our hypothesis was that patients with a history of MAD would take longer to return to work and to sports after RCR, and the rate of return would be lower, than for patients without MAD.
This was a retrospective single-center study of patients who underwent arthroscopic RCR (distal supraspinatus tear). Patients who were employed and those who participated in sports before the surgery were included in the “working” and “sports” groups, respectively. The primary outcomes were the time to return to work and return to sports after surgery. The secondary outcomes were the ratio of patients returning to work and to sports at 3, 6 and 12 months; rate of return to same level of sports; need to change or stop working or sports. The effects of prior MAD on these various outcomes were determined using Bayesian multivariate analysis.
The “working” group consisted of 158 patients (of which 16.5% had MAD) and the “sports” group consisted of 118 patients (of which 17.8% had MAD). In those with a history of MAD, return to work was 21 ± 11 weeks later and the return to sports was 17 ± 8 weeks later than in those without MAD. There was a 98% probability that return to work or return to sports was delayed by at least 4 weeks in patients with history of MAD. The likelihood that patients with prior MAD who undergo RCR will completely abandon their sport was 2.8 times higher (OR = 2.8 [1; 7.8]).
We found a negative influence of prior MAD on the return to work and return to sports after RCR.
III; retrospective case-control study.
Total shoulder arthroplasty in patients with dementia or mild cognitive impairment
2024, JSES International
Anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably alleviate pain and restore shoulder function for a variety of indications. However, these procedures are not well-studied in patients with neurocognitive impairment. Therefore, the purpose of this study was to investigate whether patients with dementia or mild cognitive impairment (MCI) have increased odds of surgical or medical complications following arthroplasty.
The PearlDiver database was queried from 2010 through October 2021 to identify a cohort of patients who underwent either ATSA or RTSA and had a minimum 2-year follow-up. Current Procedural Terminology and International Classification of Diseases codes were used to stratify this cohort into three groups: (1) patients with dementia, (2) patients with MCI, and (3) patients with neither condition. Surgical and medical complication rates were compared among these three groups.
The overall prevalence of neurocognitive impairment among patients undergoing total shoulder arthroplasty was 3.0% in a cohort of 92,022 patients. Patients with dementia had increased odds of sustaining a periprosthetic humerus fracture (odds ratio [OR] = 1.46, P < .001), developing prosthesis instability (OR = 1.72, P < .001), and undergoing revision arthroplasty (OR = 1.55, P = .003) after RTSA compared to patients with normal cognition. ATSA patients with dementia did not have an elevated risk of surgical complications or revision. Conversely, RTSA patients with MCI did not have an elevated risk of complications or revision, although ATSA patients with MCI had greater odds of prosthesis instability (OR = 2.51, P = .008). Additionally, patients with neurocognitive impairment had elevated odds of medical complications compared to patients with normal cognition, including acute myocardial infarction and cerebrovascular accident.
Compared to patients with normal cognition, RTSA patients with preoperative dementia and ATSA patients with preoperative MCI are at increased risk for surgical complications. Moreover, both ATSA and RTSA patients with either preoperative MCI or dementia are at increased risk for medical complications. As the mean age in the U.S. continues to rise, special attention should be directed towards patients with neurocognitive impairment to minimize postoperative complications aftertotal shoulder arthroplasty, and the risks of this surgery more carefully discussed with patients and their families and caretakers.
Influence of acromioclavicular joint arthritis on outcomes after reverse total shoulder
2024, JSES International
Although substantial motion at the acromioclavicular joint (ACJ) occurs during overhead shoulder motion, the influence of ACJ arthritis on postoperative outcomes of patients undergoing reverse total shoulder arthroplasty (rTSA) is unclear. We assessed the influence of ACJ arthritis, defined by degenerative radiographic changes, and its severity on clinical outcomes after primary rTSA.
We conducted a retrospective review of a prospectively collected shoulder arthroplasty database of patients that underwent primary rTSA with a minimum 2-year clinical follow-up. Imaging studies of included patients were evaluated to assess ACJ arthritis classified by radiographic degenerative changes of the ACJ; severity was based upon size and location of osteophytes. Both the Petersson classification and the King classification (a modified Petersson classification addressing superior osteophytes and size of the largest osteophyte) were used to evaluate the severity of degenerative ACJ radiographic changes. Severe ACJ arthritis was characterized by large osteophytes (≥2 mm). Active range of motion (ROM) in abduction, forward elevation, and external and internal rotation as well as clinical outcome scores (American Shoulder and Elbow Surgeons Shoulder, Constant, Shoulder Pain and Disability Index, simple shoulder test, University of California, Los Angeles scores) were assessed both preoperatively and at the latest follow-up; outcomes were compared based on severity of ACJ arthritis. Multivariable linear regression models were used to determine whether increasing severity of ACJ arthritis was associated with poorer outcomes.
A total of 341 patients were included with a mean age of 71 ± 8 years and 55% were female. The mean follow-up was 5.1 ± 2.4 years. Preoperatively, there were no differences in outcomes based on the severity of ACJ pathology. Postoperatively, there were no differences in outcomes based upon the severity of ACJ arthritis except for greater preoperative to postoperative improvement in active internal rotation in patients with normal or grade 1 ACJ arthritis vs. grade 2 and 3 (3 ± 2 vs. 1 ± 2 and 1 ± 3, P = .029). Patients with ACJ arthritis and osteophytes ≥2 mm had less favorable Shoulder Pain and Disability Index scores, corresponding to greater pain (−49.3 ± 21.5 vs. −41.3 ± 26.8, P = .015). On multivariable linear regression, increased severity of ACJ arthritis was not independently associated with poorer postoperative ROM or outcome scores.
Overall, our results demonstrate that greater ACJ arthritis severity score is not associated with poorer outcome scores and has minimal effect on ROM. However, patients with the largest osteophytes (≥2 mm) did have slightly worse pain postoperatively. Radiographic presence of high-stage ACJ arthritis should not alter the decision to undergo rTSA.
Shoulder arthroplasty outcomes in patients with major depressive disorder or generalized anxiety disorder
2023, Seminars in Arthroplasty JSES
Anxiety and depression are among the most common mental health disorders in the United States and have been linked to increased health-care utilization and poorer clinical outcomes. However, data on the relationship between anxiety and depression and outcomes after shoulder arthroplasty (SA) are both limited and conflicting.
This retrospective cohort study examined the influence of a preoperative diagnosis of anxiety and/or major depressive disorder (MDD) on outcomes following shoulder arthroplasty, such as range of motion, pain, perioperative and postoperative complications, and readmission rates. A retrospective chart review of our health system’s electronic medical record was performed for dates of service January 2014–December 2019. Patients who underwent primary total shoulder arthroplasty or reverse total shoulder arthroplasty were considered for inclusion. These patients were then divided into two groups based on the presence or absence of an anxiety disorder and/or MDD in their past medical history.
595 patients with a minimum follow-up of one year were considered for analysis. Of these, 205 patients (34.5%) had diagnoses of an anxiety and/or MDD and were assigned to the psychiatric comorbidity group, while 390 (65.5%) were assigned to the control group. The psychiatric comorbidity group was significantly younger (68.3 ± 9.3 vs. 70.5 ± 10.0, P = .008) and more heavily female (68.7% vs. 48.7%, P < .001). The length of stay was significantly longer in the psychiatric comorbidity group than in the control group (1.9 ± 2.4 vs. 1.5 ± 0.9 days, P = .023). Postoperative range of motion, visual analog scale pain scores (1.8 ± 2.7 vs. 1.3 ± 2.3, P = .059), complication rates (7.8% vs. 6.9%, P = .681), and revision rates (4.9% vs. 3.6%, P = .448) were not significantly different between the psychiatric comorbidity and control groups, respectively. All-cause emergency department visitation and hospital readmission rates were also similar between the two groups at 30, 60, and 90 days postoperatively.
Our results suggest that a preoperative diagnosis of MDD or anxiety does not affect pain, postoperative outcomes, complications, or readmission rates following shoulder arthroplasty.

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: This systematic review of the literature did not require the approval of the Biomedical Institutional Review Board of The Ohio State University.

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Online ArticlePsychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review

Background

Methods

Results

Conclusion

Section snippets

Search strategy

Study characteristics

Discussion

Conclusion

Disclaimer

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J Shoulder Elbow Surg

J Arthroplasty

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Osteoarthritis Cartilage

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J Shoulder Elbow Surg

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Semin Arthritis Rheum

Online Article
Psychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review