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Abstract

Introduction

Upper extremity hand dominance greatly impacts the functional ability to perform activities of daily living. No studies have evaluated the effects of hand dominance on patient outcomes and postoperative range of motion (ROM) after reverse total shoulder arthroplasty (rTSA).

Methods

From 2009 to 2014, functional data and patient-reported outcomes were prospectively collected from patients who underwent rTSA at a single institution. Baseline characteristics were assessed and patients were stratified based on whether surgery was performed on the dominant extremity. A repeated-measures ANOVA was performed to determine differences in outcomes between cohorts.

Results

Eighty-seven rTSAs were performed on the patients’ dominant (DO) shoulder and 53 on the nondominant (ND) shoulder. Both groups had similar age, hospital length of stay, body mass index, and Charlson Comorbidity Index. Prior to surgery, the ND group had significantly lower active forward elevation (FE) (68°) compared to the DO group (87°, P = .04). Both groups had significant increases in FE ROM at both 1 and 2 years compared to preoperatively (P < .001). At 2 years, both groups had equivalent FE but the ND group gained significantly more than the DO group (67° vs 43°) (P = .005), mainly due to the preoperative FE. This finding was similar for shoulder abduction. Both groups had significant improvements in American Shoulder and Elbow Surgeons scores (P < .001) and Visual Analog Scale pain scores (P < .001) at 1 and 2 years postoperatively, with no significant differences between the groups.

Conclusion

rTSA is a reliable operation which consistently improves patient ROM, function, and pain scores at 2 years. However, baseline FE is higher in patients undergoing surgery for the DO extremity, which indicates an inability to tolerate as much functional deficiency compared to the ND extremity.

Keywords

Hand dominance reverse total shoulder arthroplasty reverse total shoulder replacement

Introduction

The reverse total shoulder arthroplasty (rTSA) has become an increasingly utilized treatment option for pathologies such as rotator cuff arthropathy,^1–3 massive irreparable rotator cuff tears,^4–6 revision shoulder arthroplasty,⁷ and certain 3- and 4-part proximal humerus fractures.^8,9 When conservative management such as analgesics, nonsteroidal anti-inflammatory medications, and local cortisone injections fails, rTSA has been shown to reliably relieve pain and improve function for these indications.^10–12 The success of the current Grammont rTSA design is based on maximizing deltoid function by creating a fixed fulcrum preventing proximal humeral migration as well as moving the center of rotation distally and medially in comparison to the native glenohumeral articulation, allowing forward elevation (FE) despite deficient rotator cuff function.¹³

Upper extremity hand dominance greatly impacts the functional ability to perform activities of daily living. The dominant extremity is used more for daily activities and as a result experiences increased work, which can result in not only a stronger extremity but a more sensitive extremity when injury occurs.¹⁴ In fact, Disabilities of the Arm Shoulder and Hand scores have been shown to be significantly higher when the dominant extremity is involved.¹⁵ Additionally, previous studies analyzing shoulder arthroplasty surgery have commented on hand dominance and its association with inferior clinical outcomes.^16,17

To our knowledge, no studies have evaluated the effects of hand dominance on patient outcomes and postoperative range of motion (ROM) after rTSA. We hypothesize that surgery for the dominant (DO) or nondominant (ND) extremity will result in equivalent changes in patient outcomes and shoulder ROM.

Methods

Data for this study were obtained from an Institutional Review Board-approved prospectively collected shoulder arthroplasty outcomes database maintained at the authors’ institution. The shoulder arthroplasty surgeries included in this study were performed by 3 sports medicine and shoulder fellowship-trained orthopedic surgeons (CBM, BTF, and ALZ). All three surgeons used Zimmer Trabecular Metal Reverse Shoulder System (Warsaw, IN) and followed the same rehabilitation protocol. A team of research assistants enrolled patients during clinic visits and collected demographic information and patient-reported outcome surveys on paper. Trained research assistants blinded to the procedure measured FE, abduction (ABD), ER, and IR at each follow-up visit using a goniometer. These data were then entered into a privacy-protected electronic database (Research Electronic Data Capture system).

Data Analysis

Patients were stratified based on whether surgery was performed on their dominant extremity. Elements extracted from the database included patient baseline characteristics (age, body mass index [BMI], hand dominance, Charlson Comorbidity Index [CCI], and hospital length of stay [LOS]) and patient-reported outcome scores for rTSA. Outcome measurements analyzed included shoulder ROM, strength, 12-item Short Form Health Survey (SF-12), Physical (PCS) and Mental Component Summary (MCS) scores, and American Shoulder and Elbow Surgeons (ASES) pain and function scores at baseline before surgery and at 1 and 2 years postoperatively. Patients from 2009 to 2014 were included in the study if they completed preoperative outcome scores and had a minimum of 2-year follow-up. Exclusion criteria were patients with pathologic fracture or malignant neoplasm.

Respective scores were determined using the scoring algorithms for each outcome measure. The SF-12 version 2 survey was used for this study, which included the same 12 questions as the original SF-12 survey but has been modified to improve formatting and readability. The SF-12 survey instrument includes 2 components, the Physical Component Summary (PCS) and Mental Component Summary (MCS) scales, which were used as separate outcomes in this study. Both the PCS and MCS scores were calculated from the 12-question survey; each component score ranged from 0 to 100, with a score of 0 indicating the lowest health level and a score of 100 indicating the highest health level. The ASES tool included pain and function subscales that ranged from 0 to 50 for each subscale, with 0 indicating worst pain and functional loss and 50 indicating no pain and excellent function. Similarly, for the ASES instrument, the ASES pain and ASES function scores for the operative shoulder were used as separate outcomes. Additionally, the patient’s subjective perception of their shoulder function was asked using the question “What percentage of normal is your shoulder currently?”

Statistical Analysis

Analysis of primary outcome measures was performed with Student’s t tests for normally distributed data and the nonparametric Mann–Whitney U test for nonnormal data. Additionally, a repeated-measures ANOVA was performed to determine differences in shoulder ROM and patient outcomes over time. Categorical data were analyzed with Pearson’s chi-squared tests. Fisher’s exact tests were substituted if expected counts were less than five. Background differences were reported as mean ±1 SD for continuous variables and as proportions for categorical variables. For all tests, a P value of <.05 was considered significant. A priori power analysis showed that the number of patients needed to detect a 10° difference in FE (P < .05 significance level, power 80%) was 50 in each group. SAS version 9.3 software (SAS Institute Inc, Cary, NC, USA) was used for statistical analyses and data modeling.

Results

A total of 140 patients who underwent rTSA completed 2-year follow-up during the study period; 87 rTSAs were performed on the DO shoulder and 53 on the ND shoulder. The most common primary diagnosis in both groups was rotator cuff arthropathy followed by failed previous shoulder arthroplasty (Table 1). The average age of the patients was 66.5 years (95% CI [63.9, 69]) in the DO cohort and 68.4 years (95% CI [65.4, 71.4]) in the ND cohort (P = .34). Both groups had an even distribution of males and females. Both groups had similar length of stay (2.5 days, P = .88), BMI (DO 29.5 vs ND 30.7, P = .28), and CCI (DO 0.8 vs ND 1.1, P = .18). Table 1 shows the baseline demographics for all included patients. The only significant difference between the two groups was more right-sided surgeries in the DO cohort than in the ND cohort (P < .001).

Table 1.

Baseline Demographics of ND (Nondominant) and DO (Dominant) Cohorts.

	Dominant (95% CI)	Nondominant (95% CI)	P Value
Total patients	87	53
Operated extremity
Right	77 (89%)	6 (11%)	<.001
Left	10 (11%)	47 (89%)
Sex
Female	44 (51%)	26 (49%)	.83
Male	43 (49%)	27 (51%)
Age	66.5 [63.9, 69]	68.4 [65.4, 71.4]	.34
BMI	29.5 [28.1, 30.8]	30.7 [28.8, 32.5]	.28
Smoking
Never	29 (33%)	22 (42%)
Quit	52 (60%)	30 (57%)
Current	6 (7%)	1 (2%)	.31
CCI	0.8 [0.6,1.0]	1.1 [0.7,1.4]	.18
CCI with age	3.3 [2.7, 3.8]	3.4 [2.9, 3.8]	.78
Length of stay	2.5 [2.3, 2.7]	2.5 [2.2, 2.8]	.89
Diagnosis			.23
Cuff arthropathy	46 (53%)	23 (43%)
Failed arthroplasty	17 (20%)	13 (25%)
Fracture	8 (9%)	9 (17%)
Arthritis	16 (18%)	8 (15%)

BMI, body mass index; CCI, Charlson Comorbidity Index.

The ND group had significantly lower shoulder FE at baseline (68°, 95% CI [46, 90]) compared to the DO group (87°, 95% CI [72, 101], P = .04). Both groups had significant increases in FE ROM at both 1 and 2 years compared to preoperatively (P < .001). However, the increase in FE for the ND rTSA group (67°; from 68° preoperatively to 135° at 2 years) was significantly greater than that in the DO group (43°; from 87° preoperatively to 130° at 2 years) (P = .005). Similarly, the increase in ABD for the ND rTSA group (76°; from 54° preoperatively to 130° at 2 years) was significantly higher than that in the DO rTSA group (50°; from 75° preoperatively to 125° at 2 years) (P < .001). Changes in ER and IR were similar between groups and showed no difference at 2 years (Table 2, Figure 1).

Table 2.

Preoperative, 1-, and 2-Year Postoperative Range of Motion and Patient-Reported Outcomes.

	Dominant			Nondominant			P value
	Preop	1 Year	2 Year	Preop	1 Year	2 Year	ND vs DO
Range of motion
Forward elevation	87 [72,101]	133 [121,146]	130 [117,143]	68 [46,90]	135 [118,152]	135 [119,152]	.005
Abduction	75 [60,91]	125 [111,138]	125 [112,138]	54 [35,73]	124 [105,144]	130 [113,148]	<.001
External rotation	26 [15,36]	30 [21,40]	36 [27,44]	26 [12,40]	35 [21,48]	42 [31,52]	.94
Internal rotation	L4 [L2, L5]	L3 [L1, L4]	L1 [T11, L3]	S1 [L5, S2]	L2 [L1, L4]	T12 [T10, L1]	.26
Shoulder %normal	40 [31,50]	70 [62,79]	75 [66,84]	20 [15,25]	70 [61,79]	76 [68,85]	.03
VAS score	5.7 [4.6,6.7]	2.1 [1.1,3.1]	1.7 [0.7,2.6]	5.5 [4.3,6.7]	1.8 [0.9,2.6]	1.4 [0.6,2.2]	.82
SF-12 MCS	52 [48,56]	53 [49,57]	55 [51,58]	52 [46,57]	51 [44,58]	51 [46,56]	.51
SF-12 PCS	36 [32,40]	44 [40,48]	42 [38,47]	35 [30,39]	42 [36,48]	42 [36,48]	.72
ASES Pain	23 [18,29]	42 [38,46]	44 [41,47]	19 [11,27]	40 [35,45]	43 [38,49]	.81
ASES Function	15 [11,18]	32 [27,36]	33 [28,38]	12 [7,18]	30 [23,37]	29 [21,38]	.60
ASES Composite	38 [31,45]	74 [67,81]	78 [71,85]	31 [21,42]	70 [59,81]	73 [61,85]	.96

ASES, American Shoulder and Elbow Surgeons; DO, dominant; MCS, Mental Component Summary; ND, nondominant; PCS, Physical Component Summary; VAS, Visual Analog Scale.

Figure 1.

Improvement in range of motion seen from baseline to 2 years postoperatively. Significant changes between DO (dominant) and ND (nondominant) extremity are indicated by the asterisk (*).

Also notable was the change in self-reported shoulder function. DO shoulder patients had a significantly better self-reported rating of their shoulder function at the time of surgery (40%, 95% CI [31, 50]) compared to the ND cohort (20%, 95%CI [15, 25]) (P = .001). This led to a significant improvement in the ND cohort (from 20% preoperatively to 76% at 2 years) compared to the DO cohort (from 40% preoperatively to 75% at 2 years) (P = .03). Both groups had similar ASES and visual analog scale (VAS) pain scores at baseline. While both groups had significant improvements in ASES scores (P < .001) and VAS pain scores (P < .001) at 1 and 2 years postoperatively, no significant differences were found between rTSA performed in either the DO or ND shoulder (Table 2) (Figure 2, 3 and 4).

Figure 2.

Change in SF-12 MCS and PCS. While the MCS stayed relatively stable after surgery, patients improved in PCS from baseline to 1 and 2 years after surgery.

Figure 3.

Change in ASES scores. Both DO (dominant) and ND (nondominant) surgical patients improved from baseline to 1 year. Scores plateaued between 1 and 2 years.

Figure 4.

Decreases in VAS (visual analog scale) scores were seen equally between the DO and ND groups.

Discussion

As rTSA slowly rises in use, encompassing almost half of all shoulder arthroplasties performed,¹⁸ understanding how to counsel patients becomes more important. We found that patients undergoing rTSA had significantly subjective decreased functional status and ROM in the ND compared to the DO extremity. This was seen in the objective measurements of FE (68° ND vs 87° DO) and ABD (54° ND vs 74° DO), as well as patients’ subjective measurement of % normal (20% ND vs 40% DO). Yet, no differences in the 2-year outcome scores were seen. Clinicians may find this information a valuable addition to preoperative counseling, particularly for patients who are undergoing bilateral TSAs.

Previous studies have commented on hand dominance and its association with clinical outcomes. Brostrom et al.¹⁶ in 1992 stated that TSA performed in the DO extremity fared worse compared to the ND extremity without further data analysis. LeBlanc et al.¹⁷ found poorer outcomes in the dominant extremity when a hemiarthroplasty was performed for proximal humerus fractures. Conversely, Cvetanovich et al.¹⁹ found that dominant shoulders attain increased FE compared to their nondominant cohort when an anatomic TSA was performed. In our study, which focused on rTSA, we found the contrary—that patients who had rTSA performed on their ND extremity had a higher increase in FE and ABD than their DO cohorts.

Patients undergoing rTSA in the ND extremity had significantly lower preoperative ROM and subjective function scores compared to those in the DO extremity. This may be secondary to the patient’s ability to tolerate a lower functioning ND shoulder as the ND extremity is less often used for activities of daily living such as combing hair, putting on bra, toiletry, and dressing. As a result, patients may postpone shoulder replacement surgery until absolutely necessary in the ND extremity, resulting in the significantly decreased preoperative ROM and shoulder function scores. Also, because all patients eventually had similar ROM and functional outcomes at ultimate follow-up, the ND cohort experienced a significantly higher increase in ROM and shoulder function over a 2-year period. This is similar to other studies which showed that patients with lower functional scores at baseline were more likely to obtain significant benefits after surgery.^20,21

Furthermore, our study shows that final clinical outcomes after rTSA are equivalent between the ND and DO cohorts. Both groups showed significant improvement in SF-12 and ASES scores and both groups increased significantly in their ROM from preoperative to 2-year follow-up. Often, when differences are found to be statistically significant, they may not be clinically relevant. While there is not a set minimal clinical significant difference for shoulder ROM, previous studies suggested 10° to be clinically significant.¹⁹ Our preoperative difference of 20° in FE and ABD between DO and ND groups appears to significantly impact patients as evidenced by their subjective rating. A recently published article described a minimal clinical significant difference of 9 points and a substantial clinical benefit of 23 points on the ASES score.²¹ Our results reiterate the substantial clinical benefit of rTSA^22–24 showing approximately a 40-point increase for both the ND and DO cohorts in ASES scores at 2-year follow-up. Our mean postoperative ASES score of 75 points and FE of 132° is similar to that reported by Barnes et al.²² of 77.5 points and 140°, respectively, at mean follow-up of 4.8 years. This is also consistent with previous studies regarding shoulder arthroplasty.^25,26

Interestingly, while the VAS pain, SF-12, and ASES scores did not differ preoperatively between the DO and ND cohorts, patients’ self-reported rating of shoulder function did (20% ND vs 40% DO). The question “What % of normal does your shoulder feel?” appears to tease out subtle subjective differences in patient outcomes. Since the ASES score was originally developed and validated for shoulder impingement, it may not be sensitive enough to detect significant differences in severely debilitated shoulders such as those awaiting arthroplasty surgery.²⁷ Activities tested by the ASES score such as “ability to wash back/do up bra,” “comb hair,” “lift 10 lbs,” and “reach a high shelf” would be equally difficult for both the ND and DO cohorts given the limited FE and ABD preoperatively.

The strengths in our study include the prospectively collected shoulder arthroplasty outcomes database and our unbiased data collection performed by independent research assistants who used goniometers and were blinded to the surgery and hand dominance. Limitations in our study include a heterogeneous diagnosis mix, exclusion of shoulder failures, and only 2-year follow-up. However, both cohorts had no significant differences in diagnoses (Table 1) and the diagnoses are representative of the typical mix of patients in a shoulder arthroplasty practice. In our prospectively followed database, our inclusion criteria selected only for rTSA which have survived at least 2 years. As a result, we are not reporting on any shoulders that sustained infections, dislocations, or other failures. This is important in counseling patients that there are risks associated with any surgery, but if no complications occur, we can expect significant improvements in motion and function. Additionally, while we have longer follow-up for some patients, we feel it is important to report patient outcomes at minimum 2-year follow-up instead of a retrospective mean follow-up as most patients will have plateaued their improvement at that time.^6,22

Conclusion

Reverse TSA is a reliable operation which consistently improves patient ROM, function, and pain scores at 2 years. However, baseline FE and ABD is higher in patients undergoing surgery for the dominant extremity, which indicates an inability to tolerate as much functional deficiency compared to the nondominant extremity.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Effect of Hand Dominance on Range of Motion and Outcomes Following Reverse Total Shoulder Arthroplasty

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Introduction

Methods

Data Analysis

Statistical Analysis

Results

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References