As a shoulder specialist I have the pleasure of helping people get back to do doing the things they love from competitive sports to recreational activities to simply sleeping without pain. Shoulder pain and disability can have a substantial impact on one’s quality of life. My goal is help my patients get back to doing the things they enjoy. While most people don’t want to have surgery, sometimes it is an option or even necessary to achieve their goals. If surgery is an option, a reasonable question is “What are the chances I will get better?” In my practice I track the outcomes of my patients very closely. This helps me understand their outcome, provide information to patients about their anticipated outcome, and of course improve shoulder care both in my practice and for other surgeons.
I ask all of my patients to complete questionnaires about their shoulder before and after surgery using validated outcome measures. While several measures are used, two of the simplest for patients to understand are pain and the SANE score. Pain is measured on a scale of 0-10 with 0 being no pain and 10 being maximal pain. The SANE score is the one’s perception of shoulder function as a percentage of normal, 0% being no function and 100% being normal function. Below is just some of the data from our patients.
Rotator Cuff Repair
These two graphs represent all arthroscopic rotator cuff repairs in my practice. That is, small tears to massive retracted tears. As can be seen, on average a patient rates their shoulder as about 34% of normal prior to surgery and at one year they rate their shoulder as about 77% of normal. In other words, after surgery they rate their function as over double that prior to surgery. In terms of pain, patients average 5.3 out of 10 pain prior to surgery and report pain of 1.5 out of 10 after surgery. Notably, the majority of pain reduction occurs within the first 6 months, and particularly in the first 2 weeks after surgery.
As a shoulder specialist I am often referred patients who have failed previous surgery. Some of these people can benefit from a revision arthroscopic repair. With the outcomes system I use I’m able to compare my data to other surgeons across the country. The two graphs below represent my outcomes in revision arthroscopic rotator cuff repair compared to other surgeons. The green lines represent my patients and the black line represents other surgeons. As one can see, my patients have a similar function prior to surgery and appear to be doing similar to or slightly better than other patients. In terms of pain, my patients actually have higher pain prior to surgery and have lower pain after surgery compared to other surgeons.
The two graphs below represent the outcome of my patients after an anatomic total shoulder replacement. Prior to surgery patients rate their shoulder at about 27% of normal. After surgery they rate their shoulder at about 76% of normal, or 3 times better than before surgery. Their pain averages 6.6 prior to surgery and decreases to an average of 1.6 out of 10 after surgery.
Reverse shoulder arthroplasty is another type of replacement that is used particularly in patients with both arthritis and rotator cuff insufficiency. The two graphs below represent my outcomes in these patients. On average a patient reports function of 26% of normal prior to surgery and 71% of normal after surgery. Pain averages 5.4 out of 10 prior to surgery and decreases to an average of 1.2 out of 10 after surgery.
Complications and Volume
Prior to surgery I try to help my patients understand their chances of success and chances of a complication. In other words we have a risk vs. benefit discussion. Risk and benefits depend on both the patient and the surgeon. For instance a healthy patient with a small rotator cuff tear is more likely to have a good result with minimal complications than an unhealthy patient with a massive rotator cuff tear. In addition the results between surgeons are not the same. While surgeon skill no doubt varies, it is difficult to measure. As a surrogate, many studies have measured surgeon volume and outcome. Time and time again these studies have shown that outcome is better, cost is lower, and complication is lower when surgery is performed by a high-volume surgeon. As we have learned with the “10,000 hour rule,” it takes time to become an expert in an area and the more we do, in general the better we become. However, most shoulder replacements are performed by a surgeon who does less than 10 per year. In my practice as a shoulder specialist I perform over 125 shoulder replacements per year and over 200 rotator cuff repairs per year.
One of the complications I follow most closely is the risk of infection since this complication can be devastating. I take several measures to prevent infection and with these I have a very low infection rate. In published studies the risk of shoulder infection following shoulder replacement is 1-4%. In my patients the infection rate is less than 1%. Similarly, my infection rate following arthroscopic surgery is less than 1%.