Glenohumeral Osteoarthritis in Young Patients: When is Arthroscopic Management Indicated? A Markov Decision Analysis

Authors:

Ulrich Spiegl, M.D., Scott Faucett, M.D., Marilee Horan, M.P.H., Peter Millett, M.D., M.Sc.

Abstract:

Introduction

There is little information to guide clinicians about the best treatment for young patients with glenohumeral osteoarthritis (OA). The purpose of this study was to perform a decision analysis comparing arthroscopic management with total shoulder arthroplasty (TSA) for the surgical treatment of glenohumeral OA and to determine the effect of age at surgery on the long-term outcome of each strategy.

Methods

A Markov decision model was constructed to compare arthroscopic management and TSA in patients with glenohumeral OA. The rates of surgical complications, revision surgery, and death were derived from the literature for each treatment. Additionally, the outcomes, complication rates, revision surgery rates, and the survivorship after arthroscopic management and TSA were included. Outcomes were measured as quality-adjusted life years (QALYs) and the principal outcome measure was the mean QALYs for each strategy. The model was tested over a range of ages to determine the sensitivity of the outcome based on the age at the initial procedure.

Results

The model demonstrated that arthroscopic management was the preferred treatment strategy for patients under 47 and that TSA was the preferred treatment strategy for those over 65 years old. The model was sensitive to a number of factors which included: (1) age at the initial surgery, (2) utilities of the well states after TSA and arthroscopic management, (3) survivorship of TSA and arthroscopic management, and (4) the probability of failure for arthroscopic management and TSA. For the analysis in this young and active population, the utility after arthroscopic management was assumed to be 0.82, while the utility after TSA was set at 0.85. The model was quite sensitive to changes in the utility, and a reduction in the utility of only 0.01 after arthroscopic management decreased the threshold age favoring arthroscopic management from 65 to 47 years.

Conclusion

Arthroscopic management for OA is the preferred initial strategy for younger patients that have failed conservative treatment, while TSA is preferred in older patients. The decision analysis was most sensitive to patient age and the utility after arthroscopic management and TSA. TSA was clearly favored in patients over 65 while arthroscopic management was preferred in those less than 47. Based on the high sensitivity of the model, the data supports two reasonable treatment strategies in patients between 47 and 65 years, where both treatment options are reasonable. Clearly, further mid- and long-term studies evaluating glenohumeral joint preserving arthroscopic strategies and TSA in young patients are warranted to help clinicians with surgical decision-making.

For the complete study: Glenohumeral Osteoarthritis in Young Patients: When is Arthroscopic Management Indicated? A Markov Decision Analysis

Peter Millett, MD

Average rating:

39 reviews

Alexandra Thompson

Mar 23, 2024

by Alexandra Thompson on Peter Millett, MD

110%

Dr. Millett and his team did a SLAP tear repair and bicep tenodesis on my left shoulder. I use my arms as an artist, and love to swim in the ocean, surf, paddle, and telemark ski. So regaining full use of my shoulder and keeping my bicep attached was very important to me. Now, over two years later, my shoulder has the equivalent range of motion as my other arm and as before the injury, and no pain. After the first three months it felt so good and was so strong that - to my horror - I completely forgot my six-month follow-up.

Not only did Dr. Millett and his team make my arm as good as new, but having had the experience of such kindness and expertise throughout the process of surgery and recovery is like an added shoulder superpower.

Thank you Rita, Brooke, Jason, Sarah, Camille, Olivia, Dr. Millett and everyone! And see you soon when my husband comes in for his knee...

Jeff Chandler

Jan 31, 2022

by Jeff Chandler on Peter Millett, MD

Flawless procedure, Easy recovery

Dr. Millet's repaired my knee and tibia, following a botched operation by a different surgeon. That procedure was virtually pain free and I was weight bearing within a few days. That was 18 years ago and the knee is still strong. A few years after the knee incident, Dr Millet repaired my shoulder. My insurance company approved me for 3 months of disability following that surgery. I was off pain medication in 2 days and had 90% range of motion within a week. I withdrew my disability claim and returned to work within two weeks of surgery. I’m not a famous athlete—just a regular guy. Nonetheless, I was treated like an NFL at the Steadman clinic. Most notable was the time for recovery. Other surgeons perform their hour-long task in the OR and don’t involve themselves in the other functions. Peter and his team manages the entire process from diagnosis, anesthesia, nursing care, and therapy. He takes a holistic approach to patient care and doesn’t skip any steps.

Jenn West

Jul 2, 2021

by Jenn West on Peter Millett, MD

Saved My Life

I went to Dr. Millett after 7 knee surgeries (6 on my right and 1 on my left) and had seen 11 different surgeons who all refused to remove femur metal from my right leg. I am highly allergic to metal and the chronic pain was leaving me bedridden for 3.5wks out of a month. He personally wrote me back on my inquiry, listened to my concerns, scheduled my surgery within a week (due to insurance issues) and personally followed up with my recovery. The level of patient care from Dr. Millett and his ENTIRE team is above any care I have ever received in my 20 years of dealing with orthopedic surgeons. There are not enough words to describe the level of care, dedication and professionalism you receive from Dr. Millett and his staff.
My only disappointment is that I did not find him sooner!!!