- Email: [email protected]
Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study
ARTICLE IN PRESS J Shoulder Elbow Surg (2016) ■■, ■■–■■
www.elsevier.com/locate/ymse
Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study Andrew Jawa, MDa,b,c,*, Umer Dasti, MDb, Amy Brown, MDd, Kathryn Grannatt, MDd, Suzanne Miller, MDb,c a
Tufts University Medical School, Boston, MA, USA The New England Baptist Hospital, Boston, MA, USA c Boston Sports and Shoulder Center, Chestnut Hill, MA, USA d Beth Israel Deaconess Hospital, Boston, MA, USA b
Background: Gender has an impact on the expectations and the outcomes of orthopedic procedures. The data examining the effect of gender on total shoulder arthroplasty (TSA) are limited but suggest that women may have worse outcomes. We performed a prospective comparison between men and women with regard to expectations and midterm functional outcomes for TSA. Methods: The study prospectively enrolled 63 patients receiving a TSA with a minimum of 3 years of follow-up. The cohort included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years.) Each patient was given a preoperative survey in which patients were asked to select 3 expectations they most hoped to gain from surgery. Functional outcomes were measured with American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores. Results: There were differences in expectations between the genders. Men chose exercise or participation in sports (24/36) whereas women chose to maintain daily routine and chores (18/27) (P < .01) as their top expectation. Both, however, chose to sleep through the night similarly as the next most important expectation. Each achieved their expectations at similar and high rates. American Shoulder and Elbow Surgeons and 12Item Short Form Health Survey scores, respectively, increased significantly but did not differ between genders. Conclusion: TSA results in excellent improvement of functional outcomes for both men and women without a significant difference at midterm follow-up. Men, on average, are younger and value participation in sports. Women hope to improve their ability to do their daily routine and chores. Both value sleeping through the night. Level of evidence: Level II; Prospective Cohort Design; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Gender; shoulder arthroplasty; functional outcomes; expectations; men; women; age
The Institutional Review Board of New England Baptist Hospital approved this study: No. 2006-013. *Reprint requests: Andrew Jawa, MD, Boston Sports and Shoulder Center, 830 Boylston Street, Suite 107, Chestnut Hill, MA 02467, USA. E-mail address: [email protected] (A. Jawa).
A number of studies indicate gender differences in the outcomes of certain orthopedic procedures.16 Specifically, some literature suggests that women have worse outcomes by certain measures after total shoulder arthroplasty (TSA). Donigan et al
1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.03.003
ARTICLE IN PRESS 2
A. Jawa et al.
found that female gender and revision shoulder arthroplasty predicted worse functional outcomes, whereas age, medical comorbidities, obesity, and preoperative range of motion did not.1 Gruson et al found that female gender predicted higher transfusion rates after TSA.4 Last, 2 large epidemiologic studies of TSA in the United States indicated that women have a significantly longer postoperative length of stay.2,11 In addition to the effects of gender, there is also increasing evidence that the patient’s expectations are measurable and have an effect on outcomes. Henn et al showed in rotator cuff repairs that patients’ preoperative expectations correlated with self-assessed outcomes.6 For TSA patients, Styron et al showed a correlation between preoperative confidence and functional outcomes.14 In the most relevant study, Henn et al showed that younger patients had higher expectations after TSA and that women and men had different expectations, with women placing a greater emphasis on improving psychological well-being and driving.5 The implication is that differing expectations by gender may affect or explain different functional outcomes. The purpose of this study was to prospectively evaluate any differences between men and women in expectations as well as in outcomes for TSA. This information may be useful in counseling patients for TSA, setting expectations, and possibly influencing patient-based outcomes. On the basis of the current literature, we hypothesized that men and women will have different expectations and that men would have better functional outcomes.
Materials and methods We prospectively studied consecutive patients undergoing unilateral primary TSA for osteoarthritis between 2007 and 2010 by a
Table I
single surgeon (S.M.) with a single implant (Stryker, Kalamazoo, MI, USA) at a single institution. All patients who were scheduled for an anatomic TSA for osteoarthritis were asked to participate in the study, and no patients refused. Revision arthroplasty and TSA for inflammatory, posttraumatic, and postcapsulorrhaphy arthritis were excluded. The rotator cuff was confirmed to be intact by further imaging with either a computed tomography or magnetic resonance imaging scan. Each patient filled out a preoperative questionnaire and was asked to select the top 3 expectations for surgery on a list of 10 items of activities of daily living (Table I). In addition, the patients completed a visual analog scale for pain, an American Shoulder and Elbow Surgeons (ASES) questionnaire, and the 12-Item Short Form Health Survey (SF-12). At a minimum of 3 years of follow-up, each patient rated the percentage at which he or she achieved each preoperative expectation and completed the visual analog scale, ASES, and SF-12.
Statistical analysis Descriptive statistics were calculated for continuous and categorical variables. Continuous variables were summarized by number of patients and mean, standard deviation, median, minimum, and maximum values in each cohort. For the continuous variables, the 2-sample t-test and Wilcoxon Mann-Whitney test were used to compare the cohort groups. The 2-sample t-test was used when the data were normally distributed; otherwise, the nonparametric method Wilcoxon Mann-Whitney was used. Categorical variables were summarized by numbers and percentages. For the categorical variables, the χ2 test and Fisher exact test were performed. The analysis was based on collected data only, and no missing values were imputed. All statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC, USA) software. The 2-tailed threshold of significance was set at P < .05.
Comparison of preoperative expectations and achievement percentage for men and women
What are your expectations for surgery?
Women No. selected (%)
1. Use public transportation or drive 2. Independently perform household chores and daily routine* 3. Participate in recreational activities such as dancing, travel, and gardening 4. Exercise or participate in sports 5. Maintain social activities, caring for someone, playing with children 6. Easily change position, sitting to standing, standing to sitting 7. Ability to sleep through the night 8. Maintain employment 9. Maintain sexual activity 10. Maintain psychological well-being
Men % Achievement (mean)
No. selected (%)
% Achievement (mean)
3 (11) 18 (67)*
75 85
1 (3) 10 (28)*
100 90
11 (41)
73
10 (28)
93
12 (44) 5 (19)
83 100
24 (67) 9 (25)
79 97
3 (11)
83
8 (22)
97
17 (63) 4 (15) 0 (0) 3 (11)
90 75
24 (67) 12 (33) 3 (8) 4 (11)
88 96 100 88
* Indicates a significant difference between men and women with P < .05.
100
ARTICLE IN PRESS 3
54.4 50.8 .15 51.4 49.5 .51 10.8 10.2 .80 VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SF-12, 12-Item Short Form Health Survey.
48.6 45.4 .16 37.8 35.3 .13 52.5 54.6 .71 87.8 85.0 .50 35.3 30.4 .25 5.4 6.3 .22 1.0 1.0 .96 6.4 7.3 .13
Preoperative Postoperative Preoperative Preoperative
Postoperative
Δ
ASES VAS pain
Comparison of functional outcome scores for men and women Table II
Understanding of the factors that affect outcomes after TSA is important for preoperative patient counseling, setting of patients’ expectations, surgical indications, and possibly reimbursement and tracking of the surgeon’s outcomes. The literature indicates that a number of factors may have a significant impact on surgical outcomes, including age, 3 diagnosis,,12 insurance type,8 education level, preoperative expectations, and possibly gender.5,6,9 In this study, we were interested in defining the effects of gender on TSA in terms of patient expectations and functional outcomes. From our data, a few conclusions stand out. First, the functional outcomes of men and women as measured by standard self-reported scores (ASES and SF-12) are the same at midterm follow-up. Second, consistent with national norms, men are typically younger than women at the time of TSA, which may contribute to certain outcome measures and expectation differences. Last, the reasons for pursuing TSA differ by gender, with men focusing more on sports participation and women on daily chores and activities. Based on the current literature, the effect of gender on overall outcomes after TSA depends on how success is defined. Women appear to stay longer in the hospital after surgery,2 have higher transfusion rates,4 and appear to be older,3 with increased age as an independent predictor of more postoperative complications.3 By these measures, women clearly appear to have a greater risk of perioperative medical
Δ
Discussion
Preoperative
SF-12 physical
Postoperative
Δ
SF-12 mental
Postoperative
Inclusion criteria were met by 74 patients, and 63 (85%) completed final follow-up at a minimum of 3 years. The average follow-up was 57.1 months (range, 42.0-71.4). The cohorts included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years). The selections of the top 3 expectations for TSA and their respective achievement percentage by gender are shown in Table I. Men chose “exercise or participate in sports” (24/ 36) and “ability to sleep through the night” (24/36) as the top expectations, with “maintain employment” as a distant third choice (12/36). Women chose “independently perform household chores and daily routine” as their top expectation (18/ 27), which was significantly different from men (P ≤ .01). Similar to men, however, the second and third expectations were “ability to sleep through the night” (17/27) and “exercise or participate in sports” (12/27). The percentage of achievement for each chosen expectation was high and similar between cohorts (Table I). Table II summarizes the preoperative and final ASES and SF-12 scores at a minimum of 3 years for men and women. Both cohorts had significant improvement in both scores without a significant difference in the absolute scores or change in scores.
Men Women P value
Δ
Results
3.0 1.3 .62
Gender differences in TSA
ARTICLE IN PRESS 4 complications. However, in the longer term, men have higher revision rates and periprosthetic infections.7 Specifically, younger men have the greatest risk of postoperative infections.13 The effects of gender on functional outcomes are less clearly defined but superficially may show worse outcomes for women. Matsen et al did find that women had lower functional outcomes scores by the 36-Item Short Form Health Survey and by the Simple Shoulder Test.10 Although valuable, this study is retrospective and is possibly confounded by a study group that had substantially different demographics than the current average TSA patient. Three-quarters of the patients were men at an average age of 64 years. Today, as seen in a large epidemiologic study, the average age is 67 years, with women accounting for >60% of TSA patients. There may have been a selection bias for the patients in the Matsen study, and the results are possibly confounded.10 Our current study is a more rigorous prospective study, with the age and gender distribution similar to this recent epidemiologic study. Donigan et al also showed worse functional outcomes for women with the Simple Shoulder Test and the Western Ontario Osteoarthritis of the Shoulder Index score. However, this study is confounded by the inclusion of hemiarthroplasties, revisions, and rheumatoid patients.1 In terms of expectations for TSA, there appears to be some fundamental gender similarities as both cohorts chose to sleep through the night and to participate in physical activities and sport in their list of the top 3 goals. However, we found that men clearly value sport much more than women do, and women value managing daily life and chores as the main priority. Importantly, both men and women achieved their goals at a high rate (Table I). Understanding of expectations is important as greater patient expectations that are met lead to better functional outcomes5,6,14; conversely, unmet expectations can lead to worse outcomes.15 The most relevant paper on this subject by Henn et al specifically examined preoperative expectations of patients before TSA.5 Similar to our study, the study of Henn et al found decreasing pain (both day and night) and performing activities of daily living as high priorities for patients. They did find a significant difference between genders as a secondary study point, with women wanting an “improved ability to drive” and a “maintenance of psychological well-being.” Although the difference in wanting to drive could fall under the broader category of “independently performing household chores and a daily routine,” we did not find any difference in desire to improve psychological well-being (Table I). Nonetheless, understanding these consistent gender differences in expectations is important in counseling TSA patients and potentially affecting outcomes. The strength of this investigation is that it is a prospective study with preoperative and postoperative validated functional outcomes scores with relatively long follow-up. It has few confounding factors in that the patients are consecutive, with few patients (<15%) lost to follow-up, and with
A. Jawa et al. surgeries performed by a single surgeon, with a single implant at a single institution, with identical protocols. The weakness of this study is that it is relatively small; the conclusions may not broadly apply to all populations receiving a TSA in different practice settings with diagnoses other than primary osteoarthritis.
Conclusions Women receiving a TSA are older than men, on average, but the functional outcomes at midterm follow-up are the same. In terms of expectations, both hoped to alleviate night pain and to improve participation in sports. However, the most important reasons for pursuing a TSA are different, with men valuing participation in sports as the most important factor, whereas women value independently performing daily activities and chores. Both achieve their expectations at high levels. These differences and similarities between genders are important to understand in counseling of patients before surgery both to understand and to set expectations appropriately.
Disclaimer Suzanne Miller is a consultant for Stryker. All the other 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.
References 1. Donigan JA, Frisella WA, Haase D, Dolan L, Wolf B, Belmont PJ Jr. Pre-operative and intra-operative factors related to shoulder arthroplasty outcomes. Iowa Orthop J 2009;29:60-6. 2. Dunn JC, Lanzi J, Kusnezov N, Bader J, Waterman BR, Belmont PJ. Predictors of length of stay after elective total shoulder arthroplasty in the United States. J Shoulder Elbow Surg 2015;24:754-9. http:// dx.doi.org/10.1016/j.jse.2014.11.042 3. Griffin JW, Hadeed MM, Novicoff WM, Browne JA, Brockmeier SF. Patient age is a factor in early outcomes after shoulder arthroplasty. J Shoulder Elbow Surg 2014;23:1867-71. http://dx.doi.org/10.1016/ j.jse.2014.04.004 4. Gruson KI, Accousti KJ, Parsons BO, Pillai G, Flatow EL. Transfusion after shoulder arthroplasty: an analysis of rates and risk factors. J Shoulder Elbow Surg 2009;18:225-30. http://dx.doi.org/10.1016/ j.jse.2008.08.005 5. Henn RF 3rd, Ghomrawi H, Rutledge JR, Mazumdar M, Mancuso CA, Marx RG. Preoperative patient expectations of total shoulder arthroplasty. J Bone Joint Surg Am 2011;93:2110-5. http://dx.doi.org/10.2106/ JBJS.J.01114 6. Henn RF 3rd, Kang L, Tashjian RZ, Green A. Patients’ preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am 2007;89:1913-9. http://dx.doi.org/10.2106/JBJS.F.00358 7. Hollatz MF, Stang A. Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005
ARTICLE IN PRESS Gender differences in TSA
8.
9.
10.
11.
12.
to 2006. J Shoulder Elbow Surg 2014;23:e267-74. http://dx.doi.org/ 10.1016/j.jse.2013.12.008 Jawa A, Dasti U, Fasulo S, Vaickus M, Curtis A, Miller S. Anatomic total shoulder arthroplasty for patients receiving workers’ compensation. J Shoulder Elbow Surg 2015;24:1694-7. http://dx.doi.org/10.1016/ j.jse.2015.04.017 Mancuso CA, Altchek DW, Craig EV, Jones EC, Robbins L, Warren RF, et al. Patients’ expectations of shoulder surgery. J Shoulder Elbow Surg 2002;11:541-9. http://dx.doi.org/10.1067/mse.2002.126764 Matsen FA III, Antoniou J, Rozencwaig R, Campbell B, Smith KL. Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. J Shoulder Elbow Surg 2000;9:465-9. Menendez ME, Baker DK, Fryberger CT, Ponce BA. Predictors of extended length of stay after elective shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:1527-33. http://dx.doi.org/10.1016/j.jse.2015.02.014 Parsons IM IV, Buoncristiani AM, Donion S, Campbell B, Smith KL, Matsen FA III. The effect of total shoulder arthroplasty on self-assessed
5
13.
14.
15.
16.
deficits in shoulder function in patients with capsulorrhaphy arthropathy. J Shoulder Elbow Surg 2007;16:S19-26. http://dx.doi.org/10.1016/ j.jse.2006.03.001 Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elbow Surg 2012;21:1534-41. http://dx.doi.org/ 10.1016/j.jse.2012.01.006 Styron JF, Higuera CA, Strnad G, Iannotti JP. Greater patient confidence yields greater functional outcomes after primary total shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:1263-7. http://dx.doi.org/ 10.1016/j.jse.2015.04.018 Tashjian RZ, Bradley MP, Tocci S, Rey J, Henn RF, Green A. Factors influencing patient satisfaction after rotator cuff repair. J Shoulder Elbow Surg 2007;16:752-8. http://dx.doi.org/10.1016/j.jse.2007.02.136 Wolf JM, Cannada L, Van Heest AE, O’Connor MI, Ladd AL. Male and female differences in musculoskeletal disease. J Am Acad Orthop Surg 2015;23:339-47. http://dx.doi.org/10.5435/JAAOS-D-14-00020
www.elsevier.com/locate/ymse
Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study Andrew Jawa, MDa,b,c,*, Umer Dasti, MDb, Amy Brown, MDd, Kathryn Grannatt, MDd, Suzanne Miller, MDb,c a
Tufts University Medical School, Boston, MA, USA The New England Baptist Hospital, Boston, MA, USA c Boston Sports and Shoulder Center, Chestnut Hill, MA, USA d Beth Israel Deaconess Hospital, Boston, MA, USA b
Background: Gender has an impact on the expectations and the outcomes of orthopedic procedures. The data examining the effect of gender on total shoulder arthroplasty (TSA) are limited but suggest that women may have worse outcomes. We performed a prospective comparison between men and women with regard to expectations and midterm functional outcomes for TSA. Methods: The study prospectively enrolled 63 patients receiving a TSA with a minimum of 3 years of follow-up. The cohort included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years.) Each patient was given a preoperative survey in which patients were asked to select 3 expectations they most hoped to gain from surgery. Functional outcomes were measured with American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores. Results: There were differences in expectations between the genders. Men chose exercise or participation in sports (24/36) whereas women chose to maintain daily routine and chores (18/27) (P < .01) as their top expectation. Both, however, chose to sleep through the night similarly as the next most important expectation. Each achieved their expectations at similar and high rates. American Shoulder and Elbow Surgeons and 12Item Short Form Health Survey scores, respectively, increased significantly but did not differ between genders. Conclusion: TSA results in excellent improvement of functional outcomes for both men and women without a significant difference at midterm follow-up. Men, on average, are younger and value participation in sports. Women hope to improve their ability to do their daily routine and chores. Both value sleeping through the night. Level of evidence: Level II; Prospective Cohort Design; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Gender; shoulder arthroplasty; functional outcomes; expectations; men; women; age
The Institutional Review Board of New England Baptist Hospital approved this study: No. 2006-013. *Reprint requests: Andrew Jawa, MD, Boston Sports and Shoulder Center, 830 Boylston Street, Suite 107, Chestnut Hill, MA 02467, USA. E-mail address: [email protected] (A. Jawa).
A number of studies indicate gender differences in the outcomes of certain orthopedic procedures.16 Specifically, some literature suggests that women have worse outcomes by certain measures after total shoulder arthroplasty (TSA). Donigan et al
1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.03.003
ARTICLE IN PRESS 2
A. Jawa et al.
found that female gender and revision shoulder arthroplasty predicted worse functional outcomes, whereas age, medical comorbidities, obesity, and preoperative range of motion did not.1 Gruson et al found that female gender predicted higher transfusion rates after TSA.4 Last, 2 large epidemiologic studies of TSA in the United States indicated that women have a significantly longer postoperative length of stay.2,11 In addition to the effects of gender, there is also increasing evidence that the patient’s expectations are measurable and have an effect on outcomes. Henn et al showed in rotator cuff repairs that patients’ preoperative expectations correlated with self-assessed outcomes.6 For TSA patients, Styron et al showed a correlation between preoperative confidence and functional outcomes.14 In the most relevant study, Henn et al showed that younger patients had higher expectations after TSA and that women and men had different expectations, with women placing a greater emphasis on improving psychological well-being and driving.5 The implication is that differing expectations by gender may affect or explain different functional outcomes. The purpose of this study was to prospectively evaluate any differences between men and women in expectations as well as in outcomes for TSA. This information may be useful in counseling patients for TSA, setting expectations, and possibly influencing patient-based outcomes. On the basis of the current literature, we hypothesized that men and women will have different expectations and that men would have better functional outcomes.
Materials and methods We prospectively studied consecutive patients undergoing unilateral primary TSA for osteoarthritis between 2007 and 2010 by a
Table I
single surgeon (S.M.) with a single implant (Stryker, Kalamazoo, MI, USA) at a single institution. All patients who were scheduled for an anatomic TSA for osteoarthritis were asked to participate in the study, and no patients refused. Revision arthroplasty and TSA for inflammatory, posttraumatic, and postcapsulorrhaphy arthritis were excluded. The rotator cuff was confirmed to be intact by further imaging with either a computed tomography or magnetic resonance imaging scan. Each patient filled out a preoperative questionnaire and was asked to select the top 3 expectations for surgery on a list of 10 items of activities of daily living (Table I). In addition, the patients completed a visual analog scale for pain, an American Shoulder and Elbow Surgeons (ASES) questionnaire, and the 12-Item Short Form Health Survey (SF-12). At a minimum of 3 years of follow-up, each patient rated the percentage at which he or she achieved each preoperative expectation and completed the visual analog scale, ASES, and SF-12.
Statistical analysis Descriptive statistics were calculated for continuous and categorical variables. Continuous variables were summarized by number of patients and mean, standard deviation, median, minimum, and maximum values in each cohort. For the continuous variables, the 2-sample t-test and Wilcoxon Mann-Whitney test were used to compare the cohort groups. The 2-sample t-test was used when the data were normally distributed; otherwise, the nonparametric method Wilcoxon Mann-Whitney was used. Categorical variables were summarized by numbers and percentages. For the categorical variables, the χ2 test and Fisher exact test were performed. The analysis was based on collected data only, and no missing values were imputed. All statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC, USA) software. The 2-tailed threshold of significance was set at P < .05.
Comparison of preoperative expectations and achievement percentage for men and women
What are your expectations for surgery?
Women No. selected (%)
1. Use public transportation or drive 2. Independently perform household chores and daily routine* 3. Participate in recreational activities such as dancing, travel, and gardening 4. Exercise or participate in sports 5. Maintain social activities, caring for someone, playing with children 6. Easily change position, sitting to standing, standing to sitting 7. Ability to sleep through the night 8. Maintain employment 9. Maintain sexual activity 10. Maintain psychological well-being
Men % Achievement (mean)
No. selected (%)
% Achievement (mean)
3 (11) 18 (67)*
75 85
1 (3) 10 (28)*
100 90
11 (41)
73
10 (28)
93
12 (44) 5 (19)
83 100
24 (67) 9 (25)
79 97
3 (11)
83
8 (22)
97
17 (63) 4 (15) 0 (0) 3 (11)
90 75
24 (67) 12 (33) 3 (8) 4 (11)
88 96 100 88
* Indicates a significant difference between men and women with P < .05.
100
ARTICLE IN PRESS 3
54.4 50.8 .15 51.4 49.5 .51 10.8 10.2 .80 VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; SF-12, 12-Item Short Form Health Survey.
48.6 45.4 .16 37.8 35.3 .13 52.5 54.6 .71 87.8 85.0 .50 35.3 30.4 .25 5.4 6.3 .22 1.0 1.0 .96 6.4 7.3 .13
Preoperative Postoperative Preoperative Preoperative
Postoperative
Δ
ASES VAS pain
Comparison of functional outcome scores for men and women Table II
Understanding of the factors that affect outcomes after TSA is important for preoperative patient counseling, setting of patients’ expectations, surgical indications, and possibly reimbursement and tracking of the surgeon’s outcomes. The literature indicates that a number of factors may have a significant impact on surgical outcomes, including age, 3 diagnosis,,12 insurance type,8 education level, preoperative expectations, and possibly gender.5,6,9 In this study, we were interested in defining the effects of gender on TSA in terms of patient expectations and functional outcomes. From our data, a few conclusions stand out. First, the functional outcomes of men and women as measured by standard self-reported scores (ASES and SF-12) are the same at midterm follow-up. Second, consistent with national norms, men are typically younger than women at the time of TSA, which may contribute to certain outcome measures and expectation differences. Last, the reasons for pursuing TSA differ by gender, with men focusing more on sports participation and women on daily chores and activities. Based on the current literature, the effect of gender on overall outcomes after TSA depends on how success is defined. Women appear to stay longer in the hospital after surgery,2 have higher transfusion rates,4 and appear to be older,3 with increased age as an independent predictor of more postoperative complications.3 By these measures, women clearly appear to have a greater risk of perioperative medical
Δ
Discussion
Preoperative
SF-12 physical
Postoperative
Δ
SF-12 mental
Postoperative
Inclusion criteria were met by 74 patients, and 63 (85%) completed final follow-up at a minimum of 3 years. The average follow-up was 57.1 months (range, 42.0-71.4). The cohorts included 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years). The selections of the top 3 expectations for TSA and their respective achievement percentage by gender are shown in Table I. Men chose “exercise or participate in sports” (24/ 36) and “ability to sleep through the night” (24/36) as the top expectations, with “maintain employment” as a distant third choice (12/36). Women chose “independently perform household chores and daily routine” as their top expectation (18/ 27), which was significantly different from men (P ≤ .01). Similar to men, however, the second and third expectations were “ability to sleep through the night” (17/27) and “exercise or participate in sports” (12/27). The percentage of achievement for each chosen expectation was high and similar between cohorts (Table I). Table II summarizes the preoperative and final ASES and SF-12 scores at a minimum of 3 years for men and women. Both cohorts had significant improvement in both scores without a significant difference in the absolute scores or change in scores.
Men Women P value
Δ
Results
3.0 1.3 .62
Gender differences in TSA
ARTICLE IN PRESS 4 complications. However, in the longer term, men have higher revision rates and periprosthetic infections.7 Specifically, younger men have the greatest risk of postoperative infections.13 The effects of gender on functional outcomes are less clearly defined but superficially may show worse outcomes for women. Matsen et al did find that women had lower functional outcomes scores by the 36-Item Short Form Health Survey and by the Simple Shoulder Test.10 Although valuable, this study is retrospective and is possibly confounded by a study group that had substantially different demographics than the current average TSA patient. Three-quarters of the patients were men at an average age of 64 years. Today, as seen in a large epidemiologic study, the average age is 67 years, with women accounting for >60% of TSA patients. There may have been a selection bias for the patients in the Matsen study, and the results are possibly confounded.10 Our current study is a more rigorous prospective study, with the age and gender distribution similar to this recent epidemiologic study. Donigan et al also showed worse functional outcomes for women with the Simple Shoulder Test and the Western Ontario Osteoarthritis of the Shoulder Index score. However, this study is confounded by the inclusion of hemiarthroplasties, revisions, and rheumatoid patients.1 In terms of expectations for TSA, there appears to be some fundamental gender similarities as both cohorts chose to sleep through the night and to participate in physical activities and sport in their list of the top 3 goals. However, we found that men clearly value sport much more than women do, and women value managing daily life and chores as the main priority. Importantly, both men and women achieved their goals at a high rate (Table I). Understanding of expectations is important as greater patient expectations that are met lead to better functional outcomes5,6,14; conversely, unmet expectations can lead to worse outcomes.15 The most relevant paper on this subject by Henn et al specifically examined preoperative expectations of patients before TSA.5 Similar to our study, the study of Henn et al found decreasing pain (both day and night) and performing activities of daily living as high priorities for patients. They did find a significant difference between genders as a secondary study point, with women wanting an “improved ability to drive” and a “maintenance of psychological well-being.” Although the difference in wanting to drive could fall under the broader category of “independently performing household chores and a daily routine,” we did not find any difference in desire to improve psychological well-being (Table I). Nonetheless, understanding these consistent gender differences in expectations is important in counseling TSA patients and potentially affecting outcomes. The strength of this investigation is that it is a prospective study with preoperative and postoperative validated functional outcomes scores with relatively long follow-up. It has few confounding factors in that the patients are consecutive, with few patients (<15%) lost to follow-up, and with
A. Jawa et al. surgeries performed by a single surgeon, with a single implant at a single institution, with identical protocols. The weakness of this study is that it is relatively small; the conclusions may not broadly apply to all populations receiving a TSA in different practice settings with diagnoses other than primary osteoarthritis.
Conclusions Women receiving a TSA are older than men, on average, but the functional outcomes at midterm follow-up are the same. In terms of expectations, both hoped to alleviate night pain and to improve participation in sports. However, the most important reasons for pursuing a TSA are different, with men valuing participation in sports as the most important factor, whereas women value independently performing daily activities and chores. Both achieve their expectations at high levels. These differences and similarities between genders are important to understand in counseling of patients before surgery both to understand and to set expectations appropriately.
Disclaimer Suzanne Miller is a consultant for Stryker. All the other 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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