Abstract
Objectives:
Rotator cuff pathology is exceedingly common with increasing prevalence in older patients and reported rates as high as 62% in adults over the age of 80 years. Rotator cuff arthropathy encompasses a spectrum of rotator cuff pathology that involves rotator cuff insufficiency, glenohumeral wear, and superior migration of the humeral head. In patients with incompetent rotator cuff muscles and/or advanced glenohumeral osteoarthritis, reverse total shoulder arthroplasty (RTSA) has become a transformative solution, offering reliable pain relief and functional benefits.
Due to the biomechanical advantages unique to the design of the RTSA, it is commonly used in the setting of rotator cuff arthropathy in the setting of failed conservative management. Significant design advances have helped improve the reliability and outcomes after RTSA; however, there are numerous risks associated with the procedure including humeral and glenoid fractures, prosthesis loosening, dislocation, instability, infection and neurologic injury. As the demand for shoulder arthroplasty continues to rise, there is a growing interest in identifying factors predictive of suboptimal outcomes. While previous studies have explored the impact of failed rotator cuff procedures on outcomes in RTSA, the inclusion of superior capsular reconstruction and tendon transfers in the surgical armamentarium for massive rotator cuff tears has introduced new variables to consider. It is often discussed that soft tissue reconstruction should be considered as a first line approach when possible, and reverse shoulder arthroplasty can be subsequently used as a secondary option when needed. However, the question remains are we compromising the outcome of RTSA by attempting a soft tissue procedure first. This study aims to (1) compare patient-reported outcome measures (PROMs), range of motion and complication rates between RTSA patients with and without prior ipsilateral soft tissue procedures, and (2) to compare outcomes across patients who had a prior failed rotator cuff repair to those with a prior failed SCR or tendon transfer. The authors hypothesize that patients with a surgical history would exhibit poorer functional outcomes, higher complication rates, and range of motion deficits at a minimum 2-year follow-up.
Methods:
Patients who underwent RTSA from 2016 to 2021 were retrospectively identified through an institutional database. Patients who underwent RTSA for a failed RCR, SCR, or TT (Prior Surgery; PS) were matched by age, gender, BMI, and concomitant latissimus dorsi tendon transfer with patients undergoing RTSA for rotator cuff tear arthropathy with no prior surgery (NPS). Primary outcome measures included MCID, SCB, PASS achievement for American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numeric Evaluation (SANE) scores. Secondary outcome measures included Veterans Rand (VR) 12 scores, complication rates, and postoperative range of motion. A sub-analysis compared outcomes in patients with a prior failed RCR to patients with a failed SCR or TT.
Results:
A total of 150 patients (PS: n=60; NPS: n=90) met inclusion criteria. The PS cohort consisted of 33 (55.0%) primary RCR, 10 (16.7%) revision RCR, 10 (16.7%) SCR, and 7 (11.7%) TT. Adjusted analysis showed the NPS cohort had higher rates of MCID (p=0.007), SCB (p<0.001), and PASS (p<0.001) achievement for ASES and higher SCB (p<0.001) and PASS (p<0.001) for SANE (Figure 1). The NPS cohort had greater forward flexion (p<0.001) at final follow-up (Figure 2). The PS cohort had higher overall complication rates (p=0.022) and prosthetic instability or dislocation (p=0.033) (Figure 3). Sub-analysis showed the SCR/TT cohort had significantly lower rates of SCB (ASES: p=0.004; SANE: p=0.034) and PASS (ASES: p=0.014; SANE: p=0.009) compared to prior RCR patients (Figure 1).
Conclusions:
Patients with a history of a failed RCR, SCR, or TT prior to RTSA have greater range of motion deficits, higher complication rates, and lower clinically significant outcome achievement rates than those without prior ipsilateral shoulder surgery.
