Psychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review

Key points

1. 01Sixteen studies were reviewed; only 3 found no difference between patients with and without the psychosocial factor of interest.
2. 02Depression, anxiety, and other mental health disorders were linked to more complications and lower function scores in 4 of 6 studies that looked at them.
3. 03Patients with active workers' compensation claims had the lowest postoperative scores; only 57% were satisfied versus 93% of others in one study.
4. 04Preoperative opioid use was tied to lower outcome and satisfaction scores in both included opioid studies.
5. 05Higher patient confidence and expectations before surgery were correlated with better function and pain outcomes in 3 studies.

How it was conducted

Design

Systematic review (PRISMA guidelines), Level IV evidence

Search

Literature search May 30, 2000 to May 30, 2019, English-language studies of Level IV evidence or higher

Included studies

16 studies (Level I to IV); all met 8 or more of 10 US Preventive Services Task Force quality criteria

Population

Adults (18+) undergoing reverse, anatomic, total, or partial shoulder arthroplasty

Factors examined

Mental health disorders, workers' compensation status, preoperative opioid use, patient expectations and confidence, resilience, allergies, marital and employment and insurance status

What they found

• Aggregate analysis of 2-year postoperative ASES scores (6 studies, 940 patients) showed patients with workers' compensation claims had the lowest postoperative ASES and the largest drop from preoperative scores.
• Pooled analysis found a 23.4-point difference in postoperative ASES between patients with and without workers' compensation claims, well above the minimal clinically important difference of 13.6 points for ASES after TSA.
• Jawa et al found final ASES significantly lower among workers' compensation patients (73.6 vs. 86.6, P = .01).
• Morris et al found only 57% of workers' compensation patients were satisfied versus 93% of controls.
• Styron et al found each 1-point increase in confidence score raised the Penn Shoulder Score function subscore by 2.65 points and the pain subscore by 1.99 points (P = .039).
• Swarup et al found higher preoperative expectations were associated with greater ASES improvement (P = .02).
• For anatomic TSA, Morris et al reported only 80% of chronic preoperative opioid users were satisfied versus 91% of non-users.
• Iannotti and Norris found preoperative posterior subluxation lowered postoperative ASES (76 vs. 86, a 10-point difference), below the 13.6-point MCID, suggesting psychosocial factors may outweigh some technical ones.

Limitations

• All included evidence was observational with levels ranging from I to IV, so causation cannot be established.
• Outcome measures were heterogeneous across studies, making pooling and comparison difficult.
• Preoperative opioid use may be confounded with other factors such as pain severity or mental health.
• Three of the 16 studies found no difference, and the overall body of evidence is graded Level IV.

Why it matters

For patients

Addressing depression, anxiety, opioid use, and realistic expectations before shoulder replacement may improve how satisfied you feel with the result.

For clinicians

Screening for mental health, opioid use, workers' compensation status, and patient expectations before shoulder arthroplasty can help identify patients at risk of poorer reported outcomes and guide counseling.

For readers

This review highlights that nonsurgical, psychosocial factors are strongly associated with shoulder replacement outcomes, though the evidence is observational rather than experimental.