JSES - 2026-04-30 - Journal Article
Defining Patient Acceptable Symptom State (PASS) Following Reverse Total Shoulder Arthroplasty to Treat Proximal Humeral Fractures Using Advita Ortho: A Retrospective Cohort Study.
Kim YH, Lehtonen E, Beall K, Elwell J, Roche C, Shah S
Topics
Key Takeaway
PASS thresholds for rTSA in proximal humeral fractures are higher in the Late treatment group across all three scores (ASES 60, CMS 66, SAS 67) compared to Early treatment (ASES 58, CMS 62, SAS 61), with SAS demonstrating the best discriminative ability (AUC 0.85 vs 0.74).
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Summary
This study defined PASS, MCID, and SCB thresholds for ASES, CMS, and SAS scores in patients undergoing rTSA for proximal humeral fractures, stratified by Early (no prior ORIF/malunion/nonunion) versus Late treatment groups using a prospectively collected multicenter database. ROC analysis identified PASS thresholds with AUCs ranging 0.65–0.85 across scores and groups, with the SAS score demonstrating the strongest discriminative ability in the Late group (AUC 0.85). Anchor-based MCID values were slightly lower in the Late group (ASES 10.31 vs 10.84), while distribution-based SCB thresholds were higher in the Early group (ASES 17.35 vs 16.49), indicating Early-treated patients required greater absolute functional gain to perceive substantial benefit.
Key Limitation
The total sample size is never reported, making it impossible to evaluate whether the cohorts were adequately powered to detect meaningful differences in PASS thresholds between Early and Late groups.
Original Abstract
BACKGROUND
Proximal humeral fractures (PHF) are common in the elderly population, and the use of reverse total shoulder arthroplasty (rTSA) as treatment has risen substantially in recent years. As opposed to statistical significance, clinical value has increasingly been utilized to evaluate outcomes, thus this study aims to define patient acceptable symptom state (PASS) thresholds, minimal clinically important differences (MCID), and substantial clinical benefit (SCB) values for American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score (CMS), and Shoulder Arthroplasty Smart (SAS) score in patients undergoing rTSA for PHFs.
METHODS
A prospectively collected multicenter database inclusive of 43 clinical sites using Advita Ortho implant system was queried for patients receiving who underwent reverse total shoulder arthroplasty for proximal humeral fracture with a minimum of 2 years follow-up between 2007 and 2024. Patients were divided into Early (no prior ORIF, malunion, or nonunion) and Late (history of ORIF, malunion, or nonunion) treatment groups. Prospectively, outcome metrics including preoperative and postoperative CMS, ASES score, SAS score, active range of motion, visual analog scale (VAS) pain scores, self-reported shoulder function score, and patient satisfaction rate were collected from the electronic medical record. Receiver operating characteristic (ROC) curve analysis was used to determine the PASS thresholds while MCID and SCB values were determined via anchor-based methods and distribution-based methods, respectively.
RESULTS
PASS thresholds were numerically higher in the Late group across all measures. Postoperative ASES, CMS, and SAS scores all showed good discriminative ability for identifying patients who achieved PASS. Optimal PASS thresholds were 58 (AUC = 0.73) and 60 (AUC = 0.80) for ASES, 62 (AUC = 0.65) and 66 (AUC = 0.77) for CMS, and 61 (AUC = 0.74) and 67. (AUC = 0.85) for SAS in the Early and Late groups, respectively. Anchor-based MCID values were slightly lower in the Late group, suggesting that a smaller score change was needed for perceived improvement by patients (ASES: 10.84 and 10.31;
CMS
9.59 and 8.54;
SAS
10.75 and 7.60). Distribution-based SCB thresholds were observed to have higher values in the Early group, indicating that patients treated earlier required greater functional improvement to perceive substantial benefit (ASES: 17.35 and 16.49;
CMS
15.35 and 13.67;
SAS
17.19 and 12.16).
CONCLUSION
In patients undergoing reverse total shoulder arthroplasty for proximal humeral fracture, PASS thresholds for ASES, CMS, and SAS demonstrate good discriminative ability for identifying clinically meaningful improvement. Thresholds are reported separately for Early and Late treatment cohorts and should be interpreted as descriptive benchmarks.