Functional Internal Rotation is Associated with Subscapularis Tendon Healing and Increased Scapular Tilt after Grammont style BIO RSA with 155° humeral implant.

BACKGROUND: While forward flexion consistently improves after reverse shoulder arthroplasty (RSA), restoration of internal rotation behind the back (IR1) is much less predictable. This study aims to evaluate the role of the subscapularis tendon in restoration of IR and identify other factors that may influence IR such as anterior scapular tilt and postoperative passive internal rotation at 90° of abduction (IR2). The hypothesis was that IR1 is positively associated with both subscapularis healing, postoperative passive IR2, and anterior scapular tilt. METHODS: A retrospective review was performed on a consecutive series of Grammont style BIO (bony increased offset) RSAs performed by a single surgeon between January 2014 and December 2015. Inclusion criteria were: (1) primary RSA for rotator cuff arthropathy, massive irreparable rotator cuff tear, or primary osteoarthritis with B2 glenoid morphology, (2) minimum of two years clinical follow-up, and (3) complete intraoperative repair of a repairable subscapularis tendon. The primary outcomes were postoperative return of IR1 compared to postoperative IR2, healing rate of subscapularis tendon, and scapular tilt. RESULTS: The cohort included 77 patients, aged 72.6±7.0 years at index surgery and comprising 32 men (42%) and 45 women (58%). At a mean follow-up of 3.3±1.0 years, ultrasound evaluation revealed a successful repair of the subscapularis in 41 patients (53%). Healed subscapularis repair was significantly associated with greater IR1 (85% vs. 53%, p=0.031). A multivariate logistic regression revealed functional postoperative IR1 was independently associated with subscapularis healing (OR, 4.3; 95%CI [1.1-20.2]; p=0.046) as well as greater anterior tilt (OR, 1.2; 95%CI [1.1-1.5]; p=0.008) and postoperative IR2 (OR, 1.09; 95%CI [1.05-1.14]; p<0.001) but lower postoperative passive abduction (OR, 0.96; 95%CI [0.92-1.00], p=0.045). The area under receiver operating characteristic curve obtained with the Youden index was 0.88 with a sensitivity of 81.8% and specificity of 90.6%. CONCLUSIONS: This study revealed that in a Grammont-type RSA, postoperative IR1 recovery is first associated with subscapularis tendon healing, followed by IR2 and finally the ability to tilt the scapula anteriorly. Better understanding of these factors preoperatively may provide greater insight on expected return of functional internal after RSA.

Are Lower Passive Anterior Elevation and External Rotation at 6 Weeks Postoperatively Associated With Healing of Isolated Arthroscopic Supraspinatus Repairs?

BACKGROUND: Despite advancements in surgical technique, failure of tendon healing remains a common problem after arthroscopic rotator cuff repair (ARCR). PURPOSE/HYPOTHESIS: The purpose of this study was to examine the relationship between range of motion (ROM) recovery and healing after ARCR. It was hypothesized that an early loss of ROM would be associated with tendon healing. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This was a retrospective comparative study of primary ARCR of isolated full-thickness supraspinatus (SSN) tendon tears. Cases were retrieved from a prospective rotator cuff repair database and divided into 2 groups based on healing (healed/nonhealed). A standardized clinical evaluation was performed before and at 6 weeks, 3 months, and 6 months after surgery. Collected data included passive and active ROM, visual analog scale for pain, and Constant score. Healing was assessed by ultrasound at 6 months. RESULTS: Of 1397 eligible ARCRs, 1207 were included. The healing rate was 86.7%. Age was higher in the nonhealed group (57.8 ± 7.9 years vs 61.6 ± 8.8 years; P < .001). Patients with healed repairs had a larger decrease in passive anterior elevation (AE) from the preoperative to the 6-week postoperative visit (-31°± 28° vs -18°± 26°; P < .001), followed by a more substantial increase throughout the remaining follow-up period (32°± 23° vs 18°± 21°; P < .001). At 6 months postoperatively, there was no difference in AE between groups (159°± 17° vs 161°± 14°; P > .999). External rotation elbow at side (ER1) and internal rotation hand in the back (IR1) followed similar courses of recovery. Passive and active ROM had a strong positive correlation at each follow-up. Age (odds ratio [OR], 1.79; 95% CI, 1.45-2.23; P < .001) and 6-week passive AE (OR, 1.33; 95% CI, 1.20-1.48; P < .001) and ER1 (OR, 1.15; 95% CI, 1.03-1.29; P = .017) were predictors for nonhealing. CONCLUSION: Lower passive AE and ER1 at 6 weeks postoperatively and younger age are associated with healing after ARCR of isolated SSN tendon tears. At 6 months postoperatively, there were no differences in ROM, regardless of tendon healing.

Relationship between postoperative integrity of subscapularis tendon and functional outcome in reverse shoulder arthroplasty.

HYPOTHESIS AND BACKGROUND: The role of the subscapularis in reverse shoulder arthroplasty (RSA) remains controversial. Studies have shown that subscapularis repair has no significant influence on the functional outcomes of patients. However, few studies have assessed the postoperative integrity of the subscapularis tendon after RSA. The aims of this study were to investigate the postoperative healing of the subscapularis after RSA via ultrasound and to evaluate the relationship between tendon integrity and functional outcomes. We hypothesized that subjects with a healed subscapularis after RSA would have higher Constant scores and better internal rotation (IR) than those without a healed subscapularis. METHODS: This was a retrospective review of all patients who underwent primary RSA with subscapularis tenotomy repair performed by a single surgeon with a minimum 2-year follow-up period. The inclusion criteria were (1) primary RSA and (2) complete intraoperative repair of the subscapularis tenotomy if the tendon was amenable to repair. The total Constant score and active and passive range of motion were measured preoperatively and at every postoperative visit. IR was further subcategorized into 3 functional types (type I, buttock or sacrum; type II, lumbar region; and type III, T12 or higher). The integrity of the subscapularis on ultrasound at 2 years was reported using the Sugaya classification. The correlation between subscapularis integrity and functional outcomes including functional IR was evaluated. RESULTS: A total of 86 patients (mean age, 73 ± 7.4 years; age range, 50-89 years) were evaluated. The mean postoperative Constant score for all patients significantly improved from 38 points to 72 points (P < .001) at last follow-up (mean, 3.3 years). There was significant improvement in all Constant score functional subscales and in terms of range of motion. The rate of sonographic healing of the subscapularis was 52.6%. There was no difference in Constant scores between "intact" and "failed" tendon repairs; however, intact tendons demonstrated significantly better IR with no difference in external rotation (P < .01). CONCLUSION: The healing rate of the subscapularis following RSA was only 52.6%. IR function in patients with an intact subscapularis at 2 years after RSA was significantly better than in patients with failed or absent tendon repairs. Primary repair of reparable subscapularis tendons during RSA should be strongly considered.

Pre-operative factors influence the recovery of range of motion following reverse shoulder arthroplasty.

INTRODUCTION: Recently the use of reverse shoulder arthroplasty (RSA) has increased because of a clinical perception of durable functional outcome. However, some patients unexpectedly have a poor recovery of range of motion (ROM) after surgery. Objective factors such as initial diagnosis, pre- and intra-operative ROM, deltoid impairment or arm lengthening have previously been associated with anterior forward flexion (AFF). This study sought to determine if subjective pre-operative factors influence the rate and timing of ROM recovery after RSA. METHODS: Between January 2011 to January 2012, all RSAs performed by a single surgeon were prospectively enrolled in this study. The cohort was divided into two groups based on AFF <90 or ≥90 after surgery. A multivariate analysis was performed to define independent predictive factors of post-operative ROM. Factors assessed included: age, sex, dominant arm, patient activity, body mass index (BMI), pre-operative diagnosis, deltoid status, pain and Constant scores, subjective shoulder value (SSV), simple shoulder test (SST) and radiographic findings. Patients were reviewed at six weeks, and three, six, 12 and 24 months. RESULTS: One hundred and one RSAs were available for analysis. Poor post-operative AFF at six weeks was significantly related to poor pre-operative deltoid strength. Poor post-operative AFF at one-year follow-up was related to surgery of non-dominant arm, pre-operative poor AFF, pre-operative activity, poor subjective shoulder value (SSV), and a low contralateral Constant score. AFF and Constant score improved until six months and then plateaued. In contrast, both external and internal rotation continued to improve beyond six months after surgery. CONCLUSIONS: AFF and Constant scores after RSA plateau at six months after surgery whereas internal and external rotation continue to improve up to two years post operation. Several pre-operative factors including poor pre-operative AFF, surgery on the non-dominant arm, and lower SSV and Constant scores are correlated with post-operative ROM following RSA. Identification of these factors may be useful for counseling on functional expectations as well as customizing rehabilitation plans. LEVEL OF EVIDENCE: Level II, Prospective Cohort Study, Treatment Study.

Prospective evaluation of clinical and radiologic factors predicting return to activity within 6 months after arthroscopic rotator cuff repair.

BACKGROUND: This study aimed to report the outcome of patients who underwent arthroscopic rotator cuff repair (ARCR) and to determine the factors associated with return to work and activity. MATERIALS: Three hundred sixty-five patients who underwent ARCR were prospectively evaluated. The cohort was divided into 2 groups based on clinical results at 6 months. Group A consisted of patients who were considered to have a satisfactory outcome based on return to their previous professional or spare-time activities. Group B consisted of patients with an unsatisfactory outcome based on a lack of return to normal work or activities. RESULTS: Of the patients, 305 had a satisfactory outcome (group A) and 60 were categorized as having an unsatisfactory outcome (group B). On multivariate analysis, preoperative factors associated with group B included female gender and heavy manual labor. Postoperative bursitis on ultrasound at 6 months was associated with being in group B. Lack of tendon healing was not associated with group B. However, if a patient without healing had persistent pain at 6 months, the pain persisted at 9 months. CONCLUSION: ARCR is an effective procedure that leads to significant improvement in pain, function, and tendon healing in most cases. However, in 1 of 5 cases, patients were unable to resume normal activity at 6 months postoperatively. Persistent limitation at 6 months was associated with female gender, heavy manual workers, and the presence of postoperative persistent bursitis.