Participation in Work and Sport Following Reverse and Total Shoulder Arthroplasty
Authors’ Disclosure Statement: Dr. Levy reports that he is a paid consultant of Globus Medical and DJO Orthopaedics; receives research grant funding from DJO Orthopaedics, Zimmer Biomet, Wright Medical, Rotation Medical, and OrthoSpace; and receives royalties from Innomed and DJO Orthopaedics. The other authors report no actual or potential conflict of interest in relation to this article.
Dr. Kurowicki is an Orthopaedic Research Fellow, Department of Orthopaedic Surgery, Seton Hall University, School of Health and Medical Sciences, South Orange, New Jersey. Dr. Rosas is a Physician Scientist, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina. Dr. Law is an Orthopaedic Research Fellow, Department of Orthopaedic Research, Holy Cross Orthopaedic Research Institute, Fort Lauderdale, Florida. Dr. Levy is Chief of Orthopaedic Surgery, Department of Orthopaedic Surgery, Division of Shoulder and Elbow Surgery, Holy Cross Hospital, Fort Lauderdale, Florida.
Address correspondence to: Jennifer Kurowicki, MD, Seton Hall University, School of Health and Medical Sciences, 400 S Orange Ave, South Orange, NJ 07079 (email, email@example.com).
Am J Orthop. 2018;47(5). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.
Both anatomical total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are routinely performed for patients who desire to continuously work or participate in sports. This study analyzes and compares the ability of patients to work and partake in sports following shoulder arthroplasty based on responses to clinical outcome surveys.
A retrospective review of the shoulder surgery repository was performed for all patients treated with TSA and RSA and who completed questions 9 and 10 on the activity patient self-evaluation portion of the American Shoulder and Elbow Surgeons (ASES) Assessment Form. Patients with a minimum of 1-year follow-up were included if a sport or work was identified. The analysis included 162 patients with TSA and 114 patients with RSA. Comparisons were made between TSA and RSA in terms of the specific ASES scores (rated 0-3) reported for ability to work and participate in sports and total ASES scores, and scores based on specific sports or line of work reported. Comparisons were also made between sports predominantly using shoulder function and those that do not.
TSA patients had a 27% higher ability to participate in sports (average specific ASES score: 2.5 vs 1.9, P < .001) than RSA patients and presented significantly higher scores for swimming and golf. Compared with RSA patients, TSA patients demonstrated more ability to participate in sports requiring shoulder function without difficulty, as 63% reported maximal scores (P = .003). Total shoulder arthroplasty patients also demonstrated a 21% higher ability to work than RSA patients (average specific ASES scores: 2.6 vs 2.1, P < .001), yielding significantly higher scores for housework and gardening.
Both TSA and RSA allow for participation in work and sports, with TSA patients reporting better overall ability to participate. For sports involving shoulder function, TSA patients more commonly report maximal ability to participate than RSA patients.
- Both anatomic (TSA) and reverse shoulder arthroplasty (RSA) allow for the participation in work and sports.
- TSA patients report easier overall ability to participate in sports, specifically golf and swimming.
- For sports involving shoulder function, TSA patients more commonly report maximal ability to participate than RSA patients.
- TSA patients report easier overall ability to return to work-related activities, specifically housework and gardening.
- TSA patients featured 27% higher sport-specific ASES scores and 21% higher work-specific ASES scores than RSA patients.
End-stage shoulder arthritis has been successfully treated with anatomical total shoulder arthroplasty (TSA) with high rates of functional recovery.1 With the introduction of reverse shoulder arthroplasty (RSA), indications for TSA have expanded.2-6 With continuing expansion of surgical indications, a more diverse and potentially active patient population is now being treated. As patients exhibit increased awareness of health and wellness, they demonstrate significant interest in understanding their ability to work or participate in sports after surgery.7 Patients no longer focus on pain relief as the only goal of surgery. A recent study of patients aged 65 years and undergoing shoulder arthroplasty revealed that 64% of the patients listed the ability to return to sports as the main reason for undergoing surgery,8 highlighting the significance of sports play in a patient’s life. Prior to surgery, shoulder pathologies lead to impairment in function, range of motion, and pain,9 hindering a patient to participate in both work and sports. With the intervention yielding improvement to these areas6,9-13 with increased patient satisfaction,10,13 accurately tailoring patient expectations for participation in sports and work postoperatively becomes increasingly important.
Although several studies have demonstrated the ability of patients to return to sports following TSA,8,14-18 a limited number of studies discuss the return to sports following RSA.19-21 Despite known postoperative improvements, no clear consensus is reached as to which specific sports patients can return to and at what level of participation is to be expected. Surveyed members of the American Shoulder and Elbow Surgeons (ASES) universally favored full return to sports, except for contact sports for TSA patients, whereas other surgeons are more conservative to allow RSA patients to return to activities.22 To our knowledge, no other study has investigated the ability to work following RSA. Furthermore, no other study has used patient-reported outcomes to compare the quality of participation in sports or work between TSA and RSA patients following surgery. This study reports the ability of patients treated with TSA and RSA to work and participate in sports based on clinical outcome surveys. We hypothesize that TSA patients will be allowed to work and participate in sports with less difficulty than RSA patients.
Materials and Methods
Following Institutional Review Board approval, a retrospective review was performed on all patients treated with TSA or RSA and who completed questions 9 and/or 10 (by score and named usual sport and/or work) on the activity patient self-evaluation portion of the ASES23 Assessment Form between 2007 to 2014; queries were made via the Shoulder Outcomes Repository. A minimum of 12-month follow-up was required, as functional recovery has been shown to plateau or nearly plateau by 12 months.11 Patients were excluded if <12 months of follow-up was available, if they failed to provide a written answer for questions 9 or 10 on the activity patient self-evaluation portion of the ASES Assessment Form, or if they required a revision shoulder arthroplasty. A single fellowship-trained shoulder and elbow surgeon performed all procedures via the same deltopectoral approach and prescribed identical postoperative rehabilitation for both TSA and RSA patients. The database query yielded 162 TSA and 114 RSA patients, for a total of 276 patients eligible for the study.
For all patients, the most recent follow-up ASES score was used. Comparisons were made between TSA and RSA for total ASES scores and response groups for usual sport (ASES question 9) and usual work (ASES question 10). The ASES questionnaire provides patients with 4 choices for each question based on the ability to perform each activity: 0, unable to do; 1, very difficult; 2, somewhat difficult; and 3, not difficult. The questionnaire also allows the patients to identify their usual work and sports. If patients noted >1 sport or work activity, they were included within multiple subgroups. Patients were further compared by age and gender.
Work was subdivided to include retired, housework, desk jobs, prolonged standing, gardening/yard work, jobs requiring lifting, carpenter/construction, cook/food preparation, and creative jobs (Table 1). Sports were subdivided to include golf, swimming, walking, gym exercises, racquet sports, group fitness, sedentary sports, fishing and target shooting, adventure sports, team sports, bowling, biking, hiking/jogging/rollerblading, and motorcycle riding (Table 2). Sports were further subdivided into those which predominately use shoulder function and those requiring minimal shoulder function (Table 3).
Statistical analysis was performed with SPSS Version 21 (IBM). Unpaired t tests were used to determine differences between groups. A P-value of <.05 was deemed significant.
A total of 276 patients that met the inclusion criteria were eligible for the study, with 162 having undergone TSA and 114 with RSA. Overall average follow-up totaled 29 months (range, 12-91 months). RSA patients (average age, 75 years old; range, 46-88 years) were significantly older than TSA patients (average age, 69 years old; range, 32-89 years; P = .001). Significantly more women were treated with TSA (52% TSA; 48% RSA; P = .012), whereas significantly more men were treated with TSA (67% TSA; 33% RSA, P = .012). Total ASES scores were significantly higher for TSA patients than RSA patients in work (P = .012) (Table 4) but not in sports (P = .063) (Table 5) categories.
A total of 186 patients, comprising of 71 RSA and 115 TSA individuals, responded to question 9 of the ASES questionnaire (Table 5). Among usually reported sports, golf (25%), swimming (17%), and walking (18%) were the most commonly cited. RSA patients indicating a sport were significantly older than TSA patients (74 years vs 69 years, P < .001). TSA patients reported a 27% higher difference in overall ability to participate in sports, with an average ASES sport-specific score of 2.5 compared with the 1.9 for RSA patients (P < .001).
Among specific sports, TSA patients reported significantly higher scores for swimming (2.6 vs 1.8, P = .007) and golf (2.5 vs 1.8, P = .050). However, no significant differences were observed for walking, gym exercises, and racquet sports (Table 5). Among sport subsets, RSA patients were significantly older for golf (77 years vs 70 years, P = .006) and bowling (80 years vs 68 years, P = .005). Five TSA patients reported biking as their sport, whereas no RSA patient reported such activity. Within each subset of sports, no significant differences were noted in average ASES total scores.
TSA patients demonstrated a more significant ability to perform usual sports that involve shoulder function without difficulty (score of 3). In shoulder dominant sports, a total of 63% of TSA patients reported a score of 3 compared with the 39% of RSA patients (P = .003). RSA patients more often reported an inability to perform shoulder specific sports, as proven by 20% of RSA patients reporting a score of 0 compared with 4% of TSA patients (P < .001) (Table 6).
A total of 265 patients, including 106 RSA and 159 TSA patients, responded to question 10 of the ASES questionnaire. Among usually reported work, retirement (43%), housework (27%), and desk jobs (18%) were the most commonly cited. RSA patients denoting a work were significantly older than TSA patients (75 years vs 69 years, P < .001). Patients with TSA presented a 21% higher difference in the overall ability to work, featuring an average ASES work-specific score of 2.6 compared with the 2.1 for RSA patients (P < .001) (Table 4).
Among specific work activities, TSA patients reported significantly higher scores for housework (2.7 vs 2; 34% difference; P = .001) and gardening (2.8 vs 1.7; 65% difference; P = .009) in comparison with RSA patients. However, no significant differences were observed for other work activities, including retirement, desk job, prolonged standing, creative jobs, lifting jobs, or construction (Table 4). Among the work subgroups, RSA patients were older than TSA patients for the retired group (77 years vs 72 years; P < .001) and gardening (81 years vs 68 years; P = .002).
The ability to participate in sports and work is a common goal for shoulder arthroplasty patients. However, the ability at which participation occurs has not been examined. This study illustrates not only the ability to engage in usual work or sport, but provides some insights into patient-reported quality of participation. Overall, TSA patients featured 27% higher sport-specific ASES scores and 21% higher work-specific ASES scores than RSA patients, confirming our hypothesis that TSA patients can participate in work or sports with less difficulty in general. This study is the first to stratify the difficulty of participating in sports in general and in specific sports identified by patients. Although statistical analysis was performed for individual sports and work reported, the use of small cohorts possibly affected the ability to detect significant differences. The data presented in this study can thus be used as descriptive evidence of what a patient may expect to be able to do following surgery, helping to define patient expectations prior to electing to undergo shoulder arthroplasty.
Among specific sports identified by patients, a few significant differences were observed between RSA and TSA patients. However, ASES-specific scores almost universally favored TSA. Of the sport subgroups, swimming and golf showed significant differences. For swimming, this difference was fairly significant, as TSA patients demonstrated a 49% higher score than their RSA counterparts, but without differences in age or total ASES score (Table 5). Alteration in shoulder mechanics after RSA may be used to explain the difficulty in returning to swimming, as additional time may be needed to adapt to new mechanics.24 McCarty and colleagues8 demonstrated that 90% of patients following TSA fully resumed participation in swimming within 6 months of surgery, and further stated that repetitive motions of swimming caused no effects on short-term outcomes. No similar analysis of swimming has been reported for RSA patients. Based upon our findings, the average RSA patient can experience some difficulties when returning to swimming after surgery (average specific ASES score, 1.8).
Jensen and Rockwood16 were among the first to demonstrate successful return to golf of 24 patients who had undergone either TSA or hemiarthroplasty (HA), showing a 5-stroke improvement in their game. A recent study investigating patient-reported activity in patients aged 75 years and undergoing RSA showed that 23% of patients returned to high-level activity sports, such as golf, motorcycle riding, or free weights.19 All patients who participated in golf before surgery resumed playing following surgery; however, golf was listed among the top activities that patients wanted to participate in but could not for any reason.19 Our data suggest that golfers with TSA will face less difficulty returning to sports compared with their RSA counterparts (average specific ASES score, 2.5 vs 1.8, who might find golf somewhat difficult.
Although no study has provided a clear consensus as to which activities are safe to perform following shoulder arthroplasty, experts have suggested that activities that impart high loads on the glenohumeral joint should be avoided.15 Among TSA patients, McCarty and colleagues8 reported high rates of return for swimmers, golfers, and tennis players; however, relatively low rates were reported for weight lifting, bowling, and softball (20%). Within our study group, golf, swimming, and walking were listed among the most popular sports performed. Although weight lifting, bowling, and softball were less commonly identified as usual sports within our study, patients treated with TSA demonstrated more ease to participate than RSA patients. This result was observed with ASES-specific scores noted for weight lifting and gym exercises (TSA, 2.5; RSA, 2.3) and team sports, such as softball (TSA, 2; RSA, 1.3). However, for bowling, RSA patients showed a trend toward more ability (RSA, 2.7; TSA, 1.7).
Successful return to sports that involve shoulder function, such as golf and swimming, has been demonstrated for TSA.8,14,16,17 However, studies have reported that return to these sports can be difficult for RSA patients.20 Fink and colleagues19 reported that following RSA, 48.7% of patients returned to moderate-intensity sports, such as swimming and golf. Consistent with these findings, in our study, TSA patients demonstrated a significantly higher ability to participate in their usual sports without difficulty (ASES-specific score of 3). This observation may relate to lower ultimate achievements in range of motion and strength in patients treated with RSA, when compared with TSA patients,24,25 and the generalized practice of utilizing RSA for lower-demand patients (RSA patients in this study were older).
Overall, participation in work was 21% easier for TSA patients than RSA patients. Although the majority of our patients cited retirement as their primary work, which is consistent with what one would expect with the mean age of this study’s cohorts (RSA, 75 years; TSA, 69 years), housework and gardening were the only specifically identified forms of work that demonstrated significant differences between RSA and TSA patients. A few reports in the literature documented the ability to return to work after shoulder arthroplasty. In a recent report on 13 workers’ compensation patients treated with TSA, only 1 patient returned to the same job, and 54% did not return to work.26 In a study comparing 14 workers’ compensation to a matched group of controls with all members treated with RSA, the workers’ compensation group yielded a lower return-to-work rate (14.2%) than the controls (41.7%).27 In a large study of 154 TSA patients, 14% returned to work, but specific jobs were not described in this analysis.14
The results of this study suggest that more TSA patients successfully participate in low-demand activities, such as gardening or housework. Zarkadas and colleagues18 reported that 65% of TSA and 47% of HA patients successfully returned to gardening compared with 42% of RSA patients observed in a continuation study.20 This study showed that TSA patients yielded a 65% difference in ability to work in gardening and 34% difference in ability to perform housework compared with RSA patients. Based on these findings, TSA patients can expect to experience no difficulty in performing housework or gardening, whereas RSA patients may find these tasks difficult to a certain degree.
The main limitation of this study is the reporting bias that results from survey-based studies. Possibly, more people engage in specific sports or work than what were reported. This type of study also features an inherent selection bias, as patients with highly and physically demanding jobs or usual sports were less likely to have been offered either TSA or RSA. An additional important limitation is the relatively small cohorts within sport and work subgroups; the small cohorts probably underpowered the statistical results of this study and made these findings valuable mostly as descriptive observations. Larger studies focusing on each subgroup will further clarify the ability of shoulder arthroplasty to perform individual sports or work. Further studies evaluating preoperative to postoperative sports- and work-specific ASES scores would provide notable insights into the functional improvements observed within each sport or work following surgery. The relatively large study population of 276 patients strengthened the findings, which relate to the overall ability to participate in sports and work for TSA and RSA patients. Finally, the evaluated TSA and RSA patients possibly represent different groups (significant difference in age and gender) with different underlying pathologies and potentially different demands and expectations. However, comparisons among these groups of patients bear importance in defining patient expectations related to surgery. Still, the ability to participate in sport or work possibly relates more to the limitations of the implant used than patient pathology. This possibility warrants further investigation.
Both TSA and RSA allow for participation in work and sports, with TSA patients reporting easier overall ability to participate. For sports involving shoulder function, TSA patients more commonly report maximal ability to participate than RSA patients.