Abstract
Objectives:
Optimal surgical indications for massive, irreparable rotator cuff tears (RCT) without arthritis remain unclear. The purpose of this study was to compare the clinical outcomes of superior capsular reconstruction (SCR), partial rotator cuff repair (PR), and reverse total shoulder arthroplasty (rTSA) at greater than 2 years follow-up and identify any characteristics or risk factors which may correlate with outcomes.
Methods:
A retrospective analysis of prospectively collected data from a single tertiary academic medical center of consecutive patients undergoing surgical treatment for massive irreparable RCT without arthritis using SCR, PR (using interval slide and/or margin convergence), or rTSA from 01/01/2006 to 01/01/2018 was performed. Patients were required to be at least 18 years of age, have intraoperative confirmation of a massive, irreparable, RCT without arthritis, failed attempts at prior non-operative management, and a minimum of two years of clinical post-operative data. Patient demographics and pre-operative clinical findings (strength and range of motion (ROM), external rotation (ER) lag, pseudoparalysis, subscapularis function) were collected. Post-operative data included complications, patient satisfaction, strength and ROM, and patient reported outcomes (ASES, VAS, SANE). Multivariate analysis was also performed to identify risk factors.
Results:
32 patients met inclusion criteria for SCR, 24 for PR, and 42 for rTSA (mean follow-up years: SCR 3.2; PR 4.0; rTSA 3.5; p=0.02). The rTSA patients were older (66.2 years; SCR - 57.3; PR - 59.0; p=0.0001) and more likely to be female (61.9%; SCR - 12.5%; PR - 25.0%; p<0.001) than SCR or PR. SCR patients had a larger tear measured on pre-operative MRI (4.23 cm; PR - 3.64; rTSA - 3.63; p=0.01). Intra-operative evaluation demonstrated the subscapularis to be non-functional in 37.5% for SCR, 4.2% for PR, and 21.4% for rTSA (p=0.01). There were no differences in other patient demographics and characteristics (Table 1).
Pre-operative assessment demonstrated the lowest ASES scores in the rTSA group (29.48; SCR - 44.17; PR - 41.51; p=0.02), the lowest SANE scores in the SCR group (25.83; PR - 51.56; rTSA - 40.00; p=0.03), and no difference in VAS. Pre-operative active forward elevation range of motion (ROM) was significantly better in the PR group (152.29 degrees) but comparable between SCR (116.25) and rTSA (105.49; p<0.001) (Table 2). Pseudoparalysis was present in 18.8% of SCR, 0% of PR, and 14.3% of rTSA patients (p=0.08). There were no differences in the rates of positive clinical exam findings or weakness (p>0.18 for all).
Comparing pre-operative to post-operative outcomes within respective groups (Table 3), all groups saw significant post-operative improvement in strength in all planes and all patient reported outcomes (p<0.036 for all). SCR and rTSA both demonstrated improved forward elevation ROM post-operatively while PR did not (p=0.96). No group experienced a significant improvement in internal or external rotation ROM post-operatively (p>0.12 for all).
When comparing between the three groups (Table 4), rTSA had significantly worse post-operative ROM in all planes when compared to SCR and PR (p<0.003 for all). There were no differences between groups in post-operative strength in any plane (p>0.16 for all) or patient reported outcomes (ASES p=0.14; VAS p=0.86; SANE p=0.61). Patients were satisfied or somewhat satisfied in 81.2% of SCR cases, 87.5% of PR, and 95.3% of rTSA (p=0.33). Regarding surgical complications, 3 of 32 (9.4%) SCR patients required conversion to rTSA, while 3 of 24 (12.5%) PR patients required reoperation (2 revision repairs, one conversion to rTSA). There were 4 surgical complications among 42 rTSA patients (9.5%) (2 acromial stress fractures - 1 operative, 1 non-operative; 1 dislocation requiring open reduction). There were 4 non-surgical complications in the SCR group (2 falls resulting in 1 distal radius fracture and 1 HAGL lesion; 1 persistent pain; 1 persistent stiffness) and 1 stroke in the rTSA group. One SCR patient and 3 rTSA patients were deceased within the follow-up time period.
Multivariate analysis demonstrated no independent predictors of revision surgery, and the only independent predictors of patient satisfaction to be improved pre-op active ER ROM (0.03) and strength (p=0.048). However, older age (0.03), improved pre-op internal rotation (IR) strength (0.03), and having SCR (p=0.048) or PR (p=0.045) rather than rTSA were independent predictors of an improved post-op ASES score. Male gender was found to be an independent predictor of improved post-operative forward elevation ROM (p=0.03) (Table 7), while undergoing rTSA was an independent predictor of worse post-operative IR and ER ROM (p<0.009 for all).
An increased AH interval distance was an independent predictor of improved post-operative strength across groups for all planes of motion (p<0.02). The presence of pseudoparalysis pre-operatively was predictive of worse post-op ER strength (p=0.003), but no difference in any other plane (p>0.05 for all).
Conclusions:
SCR, PR, and rTSA for massive, irreparable RCT without arthritis all significantly improved post-op strength and outcome scores with >80% patient satisfaction, but with rTSA having worse post-op ROM. For all patients, increased pre-op ER ROM and strength correlated with improved patient satisfaction, while increased AH distance correlated with improved post-op strength. No further risk factors were identified, and further study is needed to continue to delineate indications for each operation.