Defining patient acceptable symptom state (PASS) following reverse total shoulder arthroplasty to treat proximal humeral fractures using the Advita Ortho database: a retrospective cohort study

Proximal humeral fractures (PHFs) 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 used to evaluate outcomes; thus, this study aims to define patient acceptable symptom state (PASS) thresholds, Minimal Clinically Important Difference (MCID), and substantial clinical benefit (SCB) values for American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant-Murley score (CMS), and Shoulder Arthroplasty Smart (SAS) score in patients undergoing rTSA for PHFs. A prospectively collected multicenter database inclusive of 43 clinical sites using Advita Ortho implant system was queried for patients who underwent rTSA for proximal humeral fracture with a minimum of 2 years' follow-up between 2007 and 2024. Patients were divided into Early (no prior open reduction and internal fixation [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 pain scores, self-reported shoulder function score, and patient satisfaction rate were collected from the electronic medical record. Receiver operating characteristic 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. 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 (area under the curve [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). In patients undergoing rTSA 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.