J Shoulder Elbow Surg (2018) 27, e323–e329

www.elsevier.com/locate/ymse

ONLINE ARTICLES

Effect of preoperative patient expectations on

outcomes after reverse total shoulder arthroplasty
Ryan C. Rauck, MDa,*, Ishaan Swarup, MDa, Brenda Chang, MS, MPHa,
David M. Dines, MDa, Russell F. Warren, MDa, Lawrence V. Gulotta, MDa,
R. Frank Henn III, MDb

a
Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
b
Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA

Background: The purpose of this study was to determine the effect of preoperative expectations on out-
comes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations
would have better outcomes.
Methods: Patients undergoing primary RSA completed the Hospital for Special Surgery’s Shoulder Ex-
pectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured
with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoul-
der Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs).
Pearson correlations were used to assess the relationship between the number of expectations and out-
comes. Differences in outcomes between those with higher and lower levels of expectations for each
expectation question were assessed by independent samples t test. Multivariable linear regression analy-
sis was used to control for potential confounding factors.
Results: We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for re-
lieving pain, improving self-care, improving ability to perform daily activities, and improving ability to
drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have
better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving night-
time pain was associated with ASES (β = 7.0, P = .048) and VAS pain scores (β = −5.9, P = .047) as well
as 2-year improvement of VAS pain (β = −6.1, P = .039). Higher expectations for improving the ability
to participate in nonoverhead sports was associated with improvements in SAS (β = 2.8, P = .020).
Conclusion: A higher level of expectations for relief of nighttime pain and improving ability to partici-
pate in nonoverhead sports is associated with improved outcomes after RSA.
Level of evidence: Level III; Retrospective Cohort Design; Treatment Study
© 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Expectations; outcomes; reverse shoulder arthroplasty; shoulder replacement; arthritis; shoulder
function

The incidence of reverse shoulder arthroplasty (RSA)

The Hospital for Special Surgery Institutional Review Board approved this is increasing, 41 as is the use of RSA compared with
study (IRB #26117).
*Reprint requests: Ryan C. Rauck, MD, Hospital for Special Surgery,
hemiarthroplasty and anatomic total shoulder arthroplasty
535 E 70th St, New York, NY 10021, USA. (TSA).32 Historically, outcome after surgery was deter-
E-mail address: rauckr@hss.edu (R.C. Rauck). mined by postoperative function as deemed by the surgeon,

1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2018.05.026
e324 R.C. Rauck et al.

imaging, range of motion, and postoperative complications.14,18 and January 2015. From our institution’s shoulder registry we iden-
However, patient-dependent assessments have become in- tified 338 patients who had undergone 347 primary RSAs for
creasingly important. diagnoses of osteoarthritis, cuff tear arthropathy, or post-traumatic
Expectations have been shown to be a significant factor arthritis. Of this cohort, 265 patients (271 RSAs) were eligible for
2-year follow-up, and 135 patients (137 RSAs) had complete pre-
for patients deciding to undergo elective procedures.27 Ex-
operative and 2-year postoperative follow-up data (51% follow-
pectations have been assessed across a variety of elective
up; Fig. 1). Preoperative differences in patients with and without
orthopedic procedures, including total knee 8,13 and hip 2-year follow-up were not significant for age, sex, body mass index,
arthroplasty,15,25,26 arthroscopic knee surgery,2,5,30 hip preser- education level, comorbidities, surgical history, laterality, arm dom-
vation surgery,28 foot and ankle procedures,3 rotator cuff inance, expectations, or American Shoulder and Elbow Surgeons
repair,37 TSA,9 hand surgery,16 and spine surgery.21,23,24 There (ASES) Standardized Shoulder Assessment Form, Shoulder Activ-
have been more limited studies of expectations compared with ity Scale (SAS), 36-Item Short Form Health Survey (SF-36) and
postoperative outcomes.10,22,26,36 visual analog scale (VAS) scores (P > .05).
Patient expectations before shoulder surgery can be cat-
egorized into pain relief, improvement in psychosocial factors,
and functional improvement, as described in the Hospital for Preoperative evaluation
Special Surgery Shoulder Surgery Expectations Survey.20 Only
a few other studies have been conducted investigating ex- Preoperative patient expectations were assessed using the vali-
dated Hospital for Special Surgery’s Shoulder Expectations Survey.20
pectations in shoulder surgery. Henn et al,10 for example,
This survey includes questions related to patient expectations after
demonstrated that greater preoperative expectations are pre-
surgery, and each expectation question had 5 possible responses: “very
dictive of outcomes after rotator cuff repair. Swarup et al36 important,” “somewhat important,” “a little important,” “I do not
similarly demonstrated that higher preoperative expecta- expect this,” and “this does not apply to me.” The total numbers of
tions are associated with improved functional outcomes in “very important” responses were summed for each patient. Aside
patients undergoing anatomic TSA for osteoarthritis. To our from the routine preoperative informed consent discussion, no de-
knowledge, no studies have analyzed the relationship between liberate attempts were made to influence patient expectations. Previous
preoperative patient expectations and outcomes after RSA. studies have demonstrated that routine preoperative counseling does
The purpose of this study was to identify patient expecta- not have a substantial effect on patient expectations when using the
tions before RSA and determine the effect of preoperative Hospital for Special Surgery Shoulder Surgery Expectations Survey.17
expectations on outcomes after primary RSA. We hypoth- In addition to the baseline expectations survey, preoperative eval-
uation also included the ASES shoulder score,31 the SAS,1 the SF-36,38
esized that greater expectations would be associated with better
and the VAS11 for pain, fatigue, and general health.
outcomes after surgery.

Materials and methods Postoperative follow-up

This study was a retrospective review of prospectively collect- Patients were reevaluated 2 years after surgery. In particular, we as-
ed data using our institution’s shoulder registry between July 2008 sessed ASES, SAS, SF-36, and VAS scores. An improvement score

338 patients (347 shoulders)

who had a primary RSA
between July 1, 2008 and
January 8, 2015

73 patients (76 shoulders)

within 2-years of surgery
265 patients (271 shoulders)
eligible for 2-year follow-up

130 patients (134

shoulders) without 2-year
follow up outcome scores
135 patients (137 shoulders)
with complete pre-operative
expectations and 2 year post-
operative outcome scores

Figure 1 Inclusion and exclusion flowchart. RSA, reverse shoulder arthroplasty.

Expectations and outcomes after RSA e325

was calculated for each measure by subtracting the preoperative score

Table I Demographic and clinical characteristics of study
from the 2-year postoperative score.
population
Variable No. % Mean SD
Statistical analysis
Patients 135 100
Demographic characteristics
Paired t tests were used to evaluate the change in patient-reported Sex
outcome measures from baseline to the 2-year follow-up. Patients Male 47 35
with missing 2-year follow-up outcomes data were compared with Female 88 65
the study population using χ2 tests and independent samples t tests. Body mass index, kg/m2 45 33 26.8 5.4
Pearson correlations were used to assess the relationship between Education
the total number of “very important” responses to the expectations Some high school 8 6
survey and the outcome measures at baseline, 2-year follow-up, and High school graduate 25 19
as an improvement score (defined by subtracting the preoperative Some college 30 22
score from the 2-year postoperative score). Questions assessing in- College graduate 37 27
dividual expectations were analyzed by comparing those who reported Masters/professional/ 29 22
a “very important” level of expectations (higher level) with those doctoral
who selected any of the other answer options (lower level) using Missing 4 3
an independent samples t test. Shoulders, No. 137 100
Multivariable linear regression models were fitted to adjust for Preoperative clinical
potential confounding variables. Variables included in the initial model characteristics
were the total number of “very important” expectations, age at surgery, Age at surgery, yr 137 100 71.4 8.8
sex, the 8 SF-36 subscales, and VAS pain, fatigue and general health. Diagnosis
Demographic and clinical characteristics that failed to achieve a P Cuff arthropathy 103 75
value of ≤.10 were removed in a backward stepwise regression. Osteoarthritis 29 21
Subgroup analysis was performed to analyze associations between Old trauma 5 4
diagnosis and responses to each expectation question as well as the Laterality
total number of high expectations. Subgroup analysis was also per- Right 87 64
formed to determine associations between age and responses to each Left 50 36
expectation question in addition to the total number of high expec- Previous joint replacement
tations. All analyses were conducted using SAS 9.3 software (SAS No 79 58
Institute Inc., Cary, NC, USA). Yes 58 42
Previous contralateral total
shoulder replacement
Results
No 127 93
Yes 10 7
The 135 patients with 2-year follow-up were an average age Dominant arm
of 71 (standard deviation, 8.8) years at surgery, and 88 (65%) Right 114 90
were women and 47 were men. Most patients had a minimum Left 12 9.5
of some college education, and the average body mass index Missing 11 0.8
was 27 (standard deviation, 5.4) kg/m2. Of the 135 patients, Preoperative scores
79 had not undergone previous replacement of any joint, and ASES Score 124 91 36.5 19.3
10 (7%) had a history of contralateral shoulder replace- Shoulder Activity Scale 127 93 6.1 5.4
Visual analog scale
ment. Only 2 of the 10 patients who had a previous
Pain 131 96 62.9 26.9
contralateral shoulder replacement had bilateral primary RSA.
Fatigue 132 96 43.9 31.4
These 2 patients had complete, separate preoperative expec- General health 134 98 43.9 27.5
tations and 2-year postoperative data for each shoulder during How bad is your pain today? 134 98 5.3 2.9
our study period. The included diagnoses were cuff tear ar-
ASES, American Shoulder and Elbow Surgeons; SD, standard deviation.
thropathy (75%), degenerative arthritis (21%), or post-
traumatic arthritis (4%; Table I). Subgroup analysis showed
there was no significant relationship between diagnosis of cuff
tear arthropathy vs. osteoarthritis and any of the preopera-
tive expectations questions or total number of high The average postoperative scores on the ASES and all VAS
expectations. measures were each significantly improved compared with
The mean number of “very important” expectations was preoperative scores (P < .001; Table III). There was no sig-
7 of 19 total. Approximately half of patients had a higher level nificant difference in age of patients with high vs. lower
of expectations for improving ability to perform daily ac- expectations for all questions, except that the expectation of
tivities, improving ability to drive or put on a seatbelt, relieving being employed for monetary reimbursement was more prev-
daytime or nighttime pain, and improving self-care (Table II). alent in younger patients (P = .043).
e326 R.C. Rauck et al.

of 2-year ASES, SAS, or VAS scores. However, a higher level

Table II Shoulder surgery expectations survey responses
of expectations for relieving nighttime pain was associated
“How important are these Expectations with better ASES (β = 7.0, P = .048) and VAS pain scores
expectations in the treatment of Higher Lower (β = −5.9, P = .047) as well as 2-year improvement of VAS
your shoulder?” level* level† pain (β = −6.1, P = .039). Higher expectations for improv-
No. % No. % ing the ability to participate in nonoverhead sports was
Relieve daytime pain 64 47 73 53 associated with improvements in SAS (β = 2.8, P = .020).
Relieve nighttime pain 67 49 69 51
Improve shoulder range of motion 50 37 85 63
Stop shoulder from dislocating 33 25 98 75 Discussion
Stop shoulder from clicking 45 33 90 67
Improve ability to carry objects over 47 34 90 66 RSA is a successful procedure with significant improve-
10 pounds ments in most outcome measures at 2 years. The results of
Improve ability to reach above 52 38 85 62 our study partially reject our hypothesis that greater preop-
shoulder level erative expectations are associated with better outcomes after
Improve ability to reach sideways 61 45 76 55
primary RSA performed for cuff arthropathy, osteoarthritis,
Improve self-care 67 50 68 50
or post-traumatic arthritis. Multivariate analysis demon-
Be employed for monetary 20 15 112 85
reimbursement strated that there was no association between the total number
Improve psychological well-being 57 43 75 57 of “very important” expectations and 2-year ASES, SAS, or
Improve ability to interact with 55 40 81 60 VAS scores. Although the total number of high expecta-
others tions was not associated with outcomes, there were particular
Improve ability to perform daily 70 51 67 49 expectations that were associated with better outcomes. A
activities higher level of expectation for relieving nighttime pain was
Improve ability to drive or put on a 73 53 64 47 associated with better ASES and VAS pain scores at 2 years.
seatbelt Similarly, higher expectations for improving the ability to par-
Improve ability to exercise or 33 24 102 76 ticipate in nonoverhead sports was associated with
participate in professional sports
improvements in SAS scores.
Improve ability to participate in 21 16 112 84
Previous studies have illustrated a significant relation-
overhead sports
Improve ability to participate in 24 18 108 82 ship between expectations and outcomes across a variety of
nonoverhead sports orthopedic procedures and subspecialties.4,7,12,15,19,34,36 For
Improve ability to participate in 58 43 78 57 example, an analysis of rotator cuff repair found that a greater
recreational activities number of preoperative expectations was predictive of better
For shoulder to be back to the way 52 38 84 62 performance on the Simple Shoulder Test, Disabilities of the
it was before this problem started Arm, Shoulder and Hand questionnaire, VAS scores, and SF-
* Higher level = responded “very important.” 36 scores.10 Another study demonstrated that a greater number
†
Lower level = responded “somewhat important,” “a little impor- of preoperative expectations for anatomic TSA were associ-
tant,” “I do not expect this,” or “this does not apply to me.” ated with improvement in ASES scores, VAS scores, and SF-
36 scores.36
The lack of an association between the number of “very
important” expectations and outcomes in this study may relate
The total number of “very important” responses to ques- to a ceiling effect. More specifically, RSA has been shown
tions on the preoperative expectations survey were evaluated to have reproducible outcomes for pain relief,6,33,40 but given
quantitatively and compared with outcomes using Pearson cor- the change in biomechanics of the shoulder, there may be a
relation coefficients. A significant correlation was found certain ceiling to achieving improvement in outcomes scores.
between a greater number of “very important” responses and Werner et al39 described changes in ASES scores that were
improvement scores in SF-36 Physical Function (P = .014) associated with a minimal clinically important difference after
and SF-36 Role Physical scores (P = .017); however, SF-36 primary anatomic and reverse TSA. They demonstrated that
data were only available in 10 patients. The number of “very higher preoperative ASES scores and undergoing reverse TSA
important” responses was not correlated with any other 2-year compared with anatomic TSA were predictors of not achiev-
outcome scores or improvement scores (Table IV). A signif- ing a minimal clinically important difference. Differences in
icant correlation was found between patient responses to all patient demographics, preoperative function, and postoper-
expectation questions and specific outcomes, except for the ative rehabilitation may also affect this relationship.
expectation for the shoulder to be back to the way it was before Similar to the study by Swarup et al36 analyzing preop-
this problem started. erative expectations and their effect on outcomes after anatomic
The multivariate analysis showed that the total number of TSA, we found a significant association between specific ex-
“very important” expectations was not a significant predictor pectations and outcomes after surgery. Their study found better
Expectations and outcomes after RSA e327

Table III Baseline and 2-year patient-reported outcome scores

Variable Pairs (No.) Baseline 2-year P value
Mean SD Mean SD
ASES score 116 36.7 19.5 75.7 19.9 <.001
Shoulder Activity Scale 112 5.9 5.4 6.7 5.1 .122
Visual analog scale
Shoulder pain 107 62.4 27.6 7.6 15.3 <.001
Fatigue 123 44.5 31.7 12.6 22.4 <.001
General health 127 43.3 27.3 15.9 22.1 <.001
SF-36
Physical function 10 55.8 33.2 51.5 34.7
Role physical 10 34.4 29.9 50.6 34.9
Bodily pain 10 37.9 18.8 56.2 28.0
General health 10 65.6 21.6 71.3 18.6
Vitality 10 57.3 24.7 61.3 15.3
Social function 10 72.5 34.8 83.8 20.5
Role emotional 10 78.3 31.7 78.3 33.8
Mental health 10 70.9 24.3 76.5 20.6
SD, standard deviation; ASES, American Shoulder and Elbow Surgeons; SF-36, 36-Item Short Form Health Survey.

ASES outcomes were associated with greater expectations activity scores at follow-up, and high expectations for re-
for nighttime pain, improved shoulder range of motion, ability lieving nighttime pain were associated with higher ASES and
to carry objects weighing more than 4.5 kg, reaching above VAS pain scores at the 2-year follow-up.
shoulder level, performing self-care, and participation in On average, patients undergoing RSA responded with the
sports.36 Our findings underscore their observation that pre- highest level of expectations to 7 of 19 questions. This finding
operative patient expectations may be associated with a greater suggests that patients undergoing primary RSA tend to have
improvement in particular outcomes that are related to that lower expectations than patients undergoing primary ana-
expectation. For example, a greater level of expectation for tomic TSA.36 One explanation for this could be that RSA
improving one’s ability to participate in nonoverhead sports patients are typically older, and a previous study of patients
was associated with a significant improvement in shoulder undergoing anatomic TSA showed that younger patients have

Table IV Correlations between total number of “very important” expectations and patient outcome measures
Variable Baseline 2-year score Improvement score
No. Pearson correlation P value No. Pearson correlation P value No. Pearson correlation P value
coefficient coefficient coefficient
ASES score 137 0.15 .099 124 0.07 .47 116 0.04 .64
Shoulder Activity Scale 126 0.07 .44 127 0.12 .17 112 −0.01 .88
Visual analog scale
Shoulder pain 111 −0.11 .25 131 −0.03 .72 107 −0.03 .75
Fatigue 127 −0.08 .35 132 −0.11 .20 123 0.04 .69
General health 129 −0.07 .46 134 −0.13 .13 127 0.08 .36
SF-36
Physical function 10 0.17 .64 59 0.15 .26 10 0.74 .014
Role physical 10 0.29 .42 59 0.07 .58 10 0.73 .017
Bodily pain 10 −0.15 .68 59 0.03 .82 10 0.38 .28
General health 10 0.07 .84 59 0.29 .025 10 0.50 .14
Vitality 10 0.27 .45 59 0.11 .42 10 0.54 .11
Social function 10 −0.26 .46 59 −0.03 .81 10 0.41 .24
Role emotional 10 −0.02 .96 59 −0.05 .72 10 0.28 .44
Mental health 10 −0.26 .47 59 −0.04 .75 10 0.40 .25
ASES, American Shoulder and Elbow Surgeons; SF-36, 36-Item Short Form Health Survey.
e328 R.C. Rauck et al.

a greater number of expectations before surgery.9 Younger pa-

tients also tend to have greater expectations than older patients Conclusion
for improvement in sports after any shoulder surgery.20 In-
terestingly, our study found no difference in age and having RSA is a successful operation with significant improve-
high expectations for sports or recreational activities. ments in patient outcome measures. Although the total
Most of the patients in our study undergoing RSA had a number of high expectations was not associated with out-
diagnosis of cuff tear arthropathy and may have experi- comes, there were particular expectations that were
enced a longer period of disability due to their cuff disease. associated with better outcomes. A higher level of expec-
A longer period of disability may have influenced their ex- tations for relieving nighttime pain was associated with
pectations of surgery. Another possibility is that the better ASES and VAS pain scores at 2 years. Higher ex-
preoperative shoulder expectations survey is not sensitive pectations for improving the ability to participate in
enough to capture the expectations of this patient popula- nonoverhead sports were associated with improvements
tion. However, the survey was developed and validated in a in SAS scores. This study improves our understanding of
heterogeneous group of shoulder pathologies, including shoul- the effect of preoperative expectations on outcomes after
der arthritis.20 RSA. Future studies are needed to determine whether any
Age may explain why RSA patients with a diagnosis of interventions can be performed to help tailor patient pre-
osteoarthritis have lower expectations than anatomic TSA pa- operative expectations to optimize outcomes after RSA.
tients. The study cohort was a mean age of 71.4 years, whereas
the mean age in a previous study examining expectations
before anatomic TSA was 67.6 years.9 An additional contri- Disclaimer
bution to the difference in expectations between RSA and
anatomic TSA for a diagnosis of osteoarthritis may depend David Dines reports other financial or material support from
on glenoid morphology. Surgeons may opt for RSA over an- Biomet, personal fees from Wright Medical Technology,
atomic TSA in patients with biconcave or dysplastic Inc., outside the submitted work, and has a patent with
glenoids.29,35 Patients with more severe osteoarthritis, as evident Zimmer, with royalties paid. Russell Warren reports stock
by biconcave or dysplastic glenoids, may have more disabil- or stock options from Ivy Sports Medicine, stock or stock
ity preoperatively and therefore possibly lower expectations. options from Orthonet, royalties from Biomet, and roy-
Overall, patients undergoing RSA have the highest level alties from Smith & Nephew, outside the submitted work.
of expectations for improving ability to perform daily ac- Lawrence Gulotta reports speaking fees from Zimmer
tivities, improving ability to drive or put on a seatbelt, relieving Biomet. The other authors, their immediate families, and
nighttime or daytime pain, and improving self-care. Reliev- any research foundation with which they are affiliated have
ing nighttime pain is an important expectation in patients not received any financial payments or other benefits from
undergoing shoulder surgery,20 and we found that it was as- any commercial entity related to the subject of this article.
sociated with significantly better ASES and VAS pain scores
at the 2-year follow-up. As a whole, this information pro-
vides shoulder surgeons with a better understanding of
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