Prior nonarthroplasty shoulder surgery and modifiable risk factors negatively affect patient outcomes after shoulder arthroplasty

Background

Total shoulder arthroplasty frequently is performed in patients with a history of shoulder surgery. The purpose of this study was to evaluate clinical outcomes after primary shoulder arthroplasty in patients with a history of nonarthroplasty shoulder surgery, and whether certain modifiable risk factors (MRFs) were negatively associated with final outcome measures. The secondary purpose was to determine if costs or complications were higher in patients with prior shoulder surgery.

Methods

We conducted a retrospective cohort study of all patients who underwent primary shoulder arthroplasty from January 2015 to December 2019 by one surgeon at one institution. Patients who received hemiarthroplasty were excluded. Univariate analysis was performed to assess the influence of prior shoulder surgery on costs, complications, and patient-reported outcome measures. Multivariable analysis was performed to determine if MRF negatively affected results, defined as anemia, malnutrition, obesity, uncontrolled diabetes, tobacco use, and opioid use.

Results

512 patients met inclusion criteria; 139 patients had at least one prior shoulder surgery. Patients with history of prior shoulder surgery were younger (65.2 ± 9.3 years vs. 70.7 ± 9.1 years, P < .001), more likely to be male (52.2% vs. 47.8%, P = .016), more likely to have smoking history (20.1% vs. 10.5%, P = .002), and borderline more likely to use preoperative opioids (47.5% vs. 38.9%, P = .078) while reporting significantly higher pain scores at final follow-up (visual analog scale for pain 1.7 ± 2.4 vs. 1.1 ± 1.9, P = .001) and lower patient-reported outcome measure (P ≤ .017 for all). The final American Shoulder and Elbow Surgeons score (ASES) score was independently negatively impacted by a history of prior surgery (β = −4.25 (−7.92, −0.56), P = .024) and other nonmodifiable factors including prosthesis type of reverse arthroplasty (β = −6.31, confidence interval [CI] −10.02, −2.60, P = .001), cardiac disease (β = −3.59, CI −7.12, −.0.07, P = .046), and any complication (β = 0.28, CI 0.19, 0.36, P < .001). The final ASES score was negatively impacted by MRF including opioid use (β = −4.08, CI: −7.32, −0.84, P < .001) and smoking status (β = −7.59, CI: −12.69, −2.49, P < .001). Males had slightly higher final ASES scores (β = 3.79, CI 0.46, 7.11, P = .026). Patients with prior surgery were more likely to have an intraoperative stress fracture [odds ratio [OR] 4.6 (1.1, 19.5), P = .038] and borderline more likely to have neurologic complication [OR 1.7 (1.0, 3.0), P = .062] or any complication [OR 1.5 (1.0, 2.3), P = .075].

Conclusion

Patients with prior shoulder surgery were younger, more likely to be male, and more likely to have a history of tobacco use and opioid use. These patients experienced worse subjective clinical outcomes and were more likely to experience a complication.