Abstract
Background
Outcomes of reverse shoulder arthroplasty (RSA) in patients with prior rotator cuff repair (RCR) remain inconsistent. The purpose of this study, therefore, was to systematically review the current outcomes literature on RSA in patients with prior RCR and to compare the results with controls without prior RCR.
Methods
A systematic review of the literature was performed, and outcome studies reporting on functional and clinical outcomes were included.
Results
A total of 11 studies encompassing 2879 shoulders were included. Improvements in postoperative patient-reported outcomes (PROs) from the baseline were higher in controls including the American Shoulder and Elbow Surgeons score (47.0 vs 39.5), Simple Shoulder Test (6.0 vs 4.9), Constant score (32.6 vs 26.4), and Visual Analog Scale for pain (−5.6 vs −4.9). Improvement in range of motion was greater in the control group, including external rotation (17° vs 11°), anterior elevation (56° vs 43°), and abduction (52° vs 43°). The overall complication rate (8% vs 5%) and revision rate (3% vs 1%) were higher in the RCR group.
Discussion
Differences in postoperative PROs and improvement from the baseline demonstrate a trend toward lower outcomes in patients with prior RCR but may be below the minimal clinically import difference.
Level of evidence
IV; systematic review
Keywords: clinical outcomes, patient-reported outcomes, reverse shoulder arthroplasty, rotator cuff repair, shoulder, systematic review
Introduction
Reverse shoulder arthroplasty (RSA) was initially designed to address the shortcomings of total shoulder arthroplasty (TSA) and hemiarthroplasty in the setting of cuff tear arthropathy (CTA) and pseuoparalysis. 1 Since its inception, the volume of RSA has continued to increase due to a combination of an aging population, improved implant design, and expanding indications.2–4 Improvements in range of motion (ROM), pain relief, and subjective shoulder function have been reported across a wide variety of primary diagnoses including CTA, massive rotator cuff tears without glenohumeral osteoarthritis (GHOA), posttraumatic osteoarthritis, rheumatoid arthritis, fracture care, failed arthroplasty, and failed rotator cuff repair (RCR).5–20
In younger patients and those with higher levels of functional demand, symptomatic cuff tears are often addressed with RCR. However, despite the high success rate of RCR, in some patients, failed RCR due to re-tear or progressive deterioration can result in increased pain and dysfunction.
Although failed RCR remains one of the many expanded indications for RSA, outcomes in this setting remain inconsistent.21–33 Several studies have reported poor functional outcomes, inferior improvements in ROM, and a higher incidence of complications among those with failed RCR, while others have reported no difference.21–26,28–32 Because an estimated 38% of patients undergoing RSA have had a prior RCR surgery, it is important to consider how RCR may affect clinical outcomes. 27 Due to alterations in native anatomy and increased surgical complexity, clarifying the influence of prior RCR on RSA outcomes will allow for more accurate risk stratification and patient counseling regarding appropriate treatment options and postoperative expectations. The purpose of this review, therefore, was to systematically review the current literature reporting on the outcomes and complications of RSA in patients with prior RCR and to compare the results with controls without prior RCR.
Materials and methods
Search strategy
A systematic review of the literature was performed according to the guidelines of the preferred reporting items for systematic review and meta-analysis (PRISMA). 34 A comprehensive search of the PubMed Central, MEDLINE, Embase, Scopus, and Cochrane Library databases from inception through October 2022 was performed. References were manually reviewed for the addition of further studies. The search strategy was determined a priori and performed using keywords for (a) reverse TSA and (b) RCR.
Eligibility and screening
Clinical outcome studies were included if they met the following inclusion criteria: (a) regarded outcomes of RSA after prior RCR and (b) had available text written in the English language. Studies were excluded if they were (a) systematic reviews/meta-analyses, letters to the editor, elemental analyses, or cases reports, (b) reported a mean follow-up of less than two years, (c) reported on less than five patients, and (d) reported outcomes of RSA after prior shoulder surgery but did not stratify results by prior RCR status. Studies were included regardless of the level of evidence.
After the removal of duplicates, the abstract and title of 1423 articles were screened, of which 1373 were determined to not meet inclusion criteria, leaving 50 studies for full-text review (Figure 1). Following full-text review, a total of 11 studies met our eligibility criteria and were included in our review. The most common reasons for exclusion were failure to report outcomes of RSA after RCR (vs prior surgery more generally) and failure to stratify outcomes by prior RCR status when mentioned.
Figure 1.
PRISMA (preferred reporting items for systematic reviews and meta-analyses) diagram demonstrating study selection process.
RCR: rotator cuff repair; RSA: reverse shoulder arthroplasty.
Methodological quality and risk of bias assessment
Study quality was assessed using the methodological index for nonrandomized studies (MINORS) criteria. The MINORS criteria are a validated scoring tool for nonrandomized studies with a score of 0 to 16 for noncomparative studies and 0 to 24 for comparative studies. 35 MINORS scores below 15 were considered to reflect poor methodological quality, scores between 15 and 19 indicated moderate quality, and scores above 19 were deemed good. All studies were reviewed by two authors, with any discrepancies resolved in consultation with the senior author.
Data collection and analysis
Data were extracted from each individual study and organized into a spreadsheet for further analysis. Extracted data included study design, level of evidence, sample size, length of follow-up, and clinical outcomes (e.g. ROM, select functional scores, postoperative complications, revision). In these cases of comparative studies, data from patients without prior RCR (controls) were also extracted for comparison.
To differentiate the statistical significance from the clinical significance, the minimal clinically important difference (MCID) for RSA was used. The MCID represents the smallest change in a treatment outcome that an individual patient perceives as clinically meaningful. 36 Specific MCID thresholds used were a change of at least 8.4 in American Shoulder and Elbow Surgeons (ASES), 8.0 in Constant, 2.4 in Simple Shoulder Test (SST), and 1.4 in Visual Analog Scale for pain (VAS-pain) scores.37–39 For the purposes of this study, the MCID values for external rotation (−5.3°), anterior elevation (−2.9°), and abduction (−1.9°) as determined by Simovitch et al. were used. 40
Due to inconsistencies in the reporting of variance associated with outcome measures, a formal meta-analysis utilizing inverse-variance weighting could not be performed. Rather, to highlight relevant trends, patients were pooled across included studies and weighted means calculated on the basis of the sample size where appropriate. Data are presented as weighted mean (range) unless otherwise specified.
Results
Study characteristics
Eleven studies with a total of 2879 shoulders met the criteria for inclusion.21–25,27–32 Of the 2879 shoulders, 998 (34.7%) had undergone prior RCR and 1881 controls (65.3%) had not. The mean age across both cohorts was 70 years (range, 46–91 years), and 61% of all surgeries occurred in female patients. Minimum follow-up was 24 months. All studies were published between 2009 and 2022, with six (55%) being published since 2017.22–24,27,30,32 One of the included articles is level II evidence (9%), 31 eight are level III (73%),23–25,27–30,32 and two are level IV (18%).21,22 One study stated that prior RCR was performed arthroscopically for all patients, 31 three specified a combination of open and arthroscopic approaches,21,24,30 and seven did not specify or stated that the information was unavailable.22,23,25,27–29,32 No study stratified outcomes based on RCR approach. The mean MINORS score of the two noncomparative studies was 11.0 (range, 10–12), indicating poor methodological quality. For the nine comparative studies, the mean score was 17.6 (range, 17–19), indicating moderate methodological quality. Outcomes from the Marigi et al. study were stratified on the basis of a preoperative diagnosis of GHOA and rotator CTA in addition to prior RCR status. 27 Characteristics of included studies are detailed in Table 1.
Table 1.
Characteristics of all included studies. a
| Study | Journal of publication | Study design | Level of evidence | Study population | Age, y | Shoulders, n | % Female | Follow-up, mo b | MINORS score c |
|---|---|---|---|---|---|---|---|---|---|
| Boileau (2009) | JSES | Retrospective case series | IV | RSA in patients with persistent pain or loss of elevation and prior RCR | 70 (48–82) | 13 | 83 | 50 (24–119) | 12/16 |
| Mulieri (2010) | |||||||||
| Prior RCR | JBJS American Volume | Retrospective cohort | III | RSA in patients with massive RCT without OA and prior RCR | 71 (52–88) | 26 | 73 | 52 (24–101) | 17/24 |
| No Prior Surgery | 34 | ||||||||
| Sadoghi (2011) | |||||||||
| Prior RCR | JSES | Prospective cohort | II | RSA for irreparable RCT in patients with prior RCR | 66 (52–83) | 29 | 56 | 42 (24–96) | 19/24 |
| No Prior RCR | 66 (54–84) | 39 | 42 (24–96) | ||||||
| Hartzler (2015) | |||||||||
| SST improvement ≤1 (cases) | JSES | Retrospective case-control | III | RSA for massive RCT without OA and prior RCR | 69 (NR) | 4 | 52 | 45 (NR) | 18/24 |
| SST improvement ≥ 2 (controls) | 73 (NR) | 19 | 38 | 43 (NR) | |||||
| Morris (2015) | |||||||||
| Prior RCR | JSES | Retrospective cohort | III | RSA in patients with prior RCR | 68 ± 11 | 27 | 60 | 38 ± 24 | 17/24 |
| No Prior RCR | 274 | ||||||||
| Shields (2017) | |||||||||
| Prior RCR | OJSM | Retrospective cohort | III | RSA in patients with prior RCR | 67 ± 10 | 83 | 54 | 25 ± 13 | 18/24 |
| No Prior Surgery | 72 ± 8 | 189 | 68 | 26 ± 13 | |||||
| Erickson (2019) | |||||||||
| Prior RCR | The Bone & Joint Journal | Retrospective cohort | III | RSA in patients with prior RCR | 69 ± 9 | 45 | 60 | 24 (minimum) | 18/24 |
| No Prior RCR (matched 3:1) | 70 ± 9 | 135 | |||||||
| Patel (2020) | |||||||||
| Prior RCR | Orthopaedics & Traumatology: Surgery & Research | Retrospective cohort | III | RSA in patients with prior RCR | 70 (54–84) | 75 | 56 | 3.8 y (2–10) | 17/24 |
| No Prior RCR (matched 1:1) | 70 (53–85) | 75 | 3.3 y (2–8) | ||||||
| Chelli (2022) | Journal of Clinical Medicine | Retrospective case series | IV | RSA in patients with prior RCR | 73 ± 9 | 153 | 74 | 5.6 y (2–20) | 10/16 |
| Dean (2022) | |||||||||
| Prior RCR | Seminars in Arthroplasty: JSES | Retrospective cohort | III | RSA in patients with CTA and prior RCR | 64 ± 9 | 86 | 63 | 36 ± 26.1 | 17/24 |
| No Prior RCR (matched 1:1) | 69 ± 7 | 106 | 61 | ||||||
| Marigi (2022) | |||||||||
| Prior RCR (GHOA) | The Journal of the American Academy of Orthopaedic Surgeons | Retrospective cohort | III | RSA in patients with prior RCR (seperated in GHOA and CTA groups) | 69 ± 8 | 161 | 63 | 42 ± 11 | 17/24 |
| No Prior Surgery (GHOA matched 2:1) | 72 ± 8 | 322 | 63 | 44 ± 23 | |||||
| Prior RCR (CTA) | 69 ± 8 | 277 | 55 | 51 ± 30 | |||||
| No Prior Surgery (CTA matched 2:1) | 72 ± 8 | 554 | 60 | 44 ± 23 |
CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; JBJS: Journal of Bone and Joint Surgery; JSES: Journal of Shoulder and Elbow Surgery; MINORS: methodological index for nonrandomized studies; NR: not reported; OA: osteoarthritis; OJSM: Orthopaedic Journal of Sports Medicine; RCR: rotator cuff repair; RCT: rotator cuff tear; RSA: reverse shoulder arthroplasty.
Values are presented as mean ± SD (range) unless noted otherwise.
Follow-up in months unless otherwise noted.
The global ideal score is 16 for noncomparative studies and 24 for comparative studies.
Patient-reported outcomes
The most commonly reported patient-reported outcome (PRO) was the ASES score which was reported in six studies (64%).23,24,27,29,30,32 The SST was utilized in five studies (45%).23,25,27,29,30 VAS-pain were reported in four studies (36%)23,29,32 and Constant scores in three (27%).21,27,31 Both RCR and control cohorts demonstrated improvements in all PROs from the baseline above the MCID. The differences observed between RCR and controls in regard to postoperative scores and improvement from the baseline were all below the defined MCID thresholds.
ASES scores
RCR shoulders demonstrated higher preoperative ASES scores (36.6 (range, 31.6–43.1)) compared with control shoulders (35.3 (range, 31.9–37.5)) (Table 2). Control shoulders demonstrated higher postoperative scores (82.3 (range, 72.8–85.0) vs 76.1 (range, 69.9–77.6)) and greater improvement from preoperative scores (47.0 (range, 39.2–52.6) vs 39.5 (range, 33.5–44.9)); however, the differences were all below the MCID (8.4).
Table 2.
Pre- and postoperative ASES scores. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Mulieri (2010) | 32.9 | 33.6 | 77.5 | 72.8 | 44.6 | 39.2 |
| Shields (2017) | 31.6 | 32.4 | 76.5 | 85.0 | 44.9 | 52.6 |
| Erickson (2019) | 43.1 | 31.9 | 76.6 | 76.1 | 33.5 | 44.5 |
| Patel (2020) | 32.4 | 36.4 | 74.5 | 78.7 | 42.1 | 42.3 |
| Dean (2022) | NR | NR | 69.9 | 83.0 | NA | NA |
| Marigi GHOA (2022) | 35.8 | 34.7 | 77.4 | 83.9 | 41.6 | 49.2 |
| Marigi CTA (2022) | 39.5 | 37.5 | 77.6 | 83.0 | 38.1 | 45.5 |
| Mean (range) | 36.6 (31.6–43.1) |
35.3 (31.9–37.5) |
76.1 (69.9–77.6) |
82.3 (72.8–85.0) |
39.5 (33.5–44.9) |
47.0 (39.2–52.6) |
ASES: American Shoulder and Elbow Surgeons; CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; NA: not applicable; NR: not reported; RCR: rotator cuff repair.
Values are presented as mean.
SST scores
SST scores were reported in five studies; however, the study authored by Hartzler et al. did not report SST scores as a continuous variable but rather dichotomized the variable by identifying patients above and below the MCID of 2 points at two-year clinical follow-up. 25 The authors then analyzed prior RCR surgery as a risk factor for poor improvement in SST scores and found no significant association between prior RCR status and SST improvement (OR 1.0 (95% CI, 0.3–3.6), p = 1.0). Among the four studies reporting SST scores as a continuous variable, preoperative scores were similar between RCR (3.8 (range, 1.9–4.4)) and control patients (3.7 (range, 1.4–3.9)) (Table 3). Postoperative scores (9.7 (range, 6.3–10.1)) vs 8.7 (range, 6.8–9.3)) and improvement from preoperative scores (6.0 (range, 4.9–6.5) vs 4.9 (range, 4.9–6.0)) were higher in the control group. Again, the differences in postoperative scores and improvement from the baseline were below the MCID (2.4).
Table 3.
Pre- and postoperative SST scores. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Mulieri (2010) | 1.9 | 1.4 | 6.8 | 6.3 | 4.9 | 4.9 |
| Patel (2020) | 2.8 | 3.5 | 8.8 | 9.5 | 6.0 | 6.0 |
| Dean (2022) | NR | NR | 6.9 | 8.8 | NA | NA |
| Marigi GHOA (2022) | 3.7 | 3.6 | 9.0 | 10.1 | 5.3 | 6.5 |
| Marigi CTA (2022) | 4.4 | 3.9 | 9.3 | 9.8 | 4.9 | 5.9 |
| Mean (range) | 3.8 (1.9–4.4) |
3.7 (1.4–3.9) |
8.7 (6.8–9.3) |
9.7 (6.3–10.1) |
4.9 (4.9–6.0) |
6.0 (4.9–6.5) |
CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; NA: not applicable; NR: not reported; RCR: rotator cuff repair; SST: simple shoulder test.
Values are presented as mean.
Constant scores
The baseline Constant score was 37.4 (range, 23.9–39.6) for RCR shoulders and 36.5 (range, 31.3–37.9) for controls (Table 4). Postoperative scores (69.1 (range, 60.0–71.1) vs 63.8 (range, 58.1–64.3)) and change from the baseline (32.6 (range, 28.7–35.6) vs 26.4 (range, 24.7–34.2)) were higher in the control group with differences below the MCID (8.0).
Table 4.
Pre- and postoperative constant scores. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Boileau (2009) | 23.9 | NA | 58.1 | NA | 34.2 | NA |
| Sadoghi (2011) | 32.7 | 31.3 | 60.3 | 60.0 | 27.6 | 28.7 |
| Marigi GHOA (2022) | 36.3 | 35.5 | 64.3 | 71.1 | 28.0 | 35.6 |
| Marigi CTA (2022) | 39.6 | 37.9 | 64.3 | 68.8 | 24.7 | 30.9 |
| Mean (range) | 37.4 (23.9–39.6) |
36.5 (31.3–37.9) |
63.8 (58.1–64.3) |
69.1 (60.0–71.1) |
26.4 (24.7–34.2) |
32.6 (28.7–35.6) |
CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; NA: not applicable; RCR: rotator cuff repair.
Values are presented as mean.
VAS-pain scores
Preoperative levels of pain were similar between RCR (6.9 (range, 6.0–7.2)) and control groups (7.0 (range, 6.6–7.1)) (Table 5). The control group reported lower postoperative pain (1.4 (range, 0.7–1.7) vs 2.0 (range 1.8–2.0)) and greater improvement from the baseline (−5.6 (range, 4.9–6.2) vs −4.9 (range, 4.0–5.2)). Differences in postoperative scores and improvement from the baseline were below the MCID (1.4).
Table 5.
Pre- and postoperative VAS-pain scores. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Mulieri (2010) | 6.0 | 6.6 | 2.0 | 1.7 | −4.0 | −4.9 |
| Shields (2017) | 7.2 | 7.1 | 2.0 | 0.9 | −5.2 | −6.2 |
| Dean (2022) | NR | NR | 1.8 | 0.7 | NA | NA |
| Mean (range) | 6.9 (6.9–7.2) |
7.0 (6.6–7.1) |
2.0 (1.8–2.0) |
1.4 (0.7–1.7) |
−4.9 (4.0–5.2) |
−5.6 (4.9–6.2) |
NA: not applicable; NR: not reported; RCR: rotator cuff repair; VAS: Visual Analog Scale.
Values are presented as mean.
ROM
ROM measurements were analyzed from a total of seven studies (64%)21,23,27,29–32 including anterior elevation in seven (64%),21,23,27,29–32 abduction in four (36%),27,29–31 and external rotation in six (55%).23,27,29–32 Both RCR and control cohorts demonstrated improvements in abduction, anterior elevation, and external rotation from the baseline above the MCID. The difference in improvement between cohorts was also above the MCID suggesting less improvement in the prior RCR group.
Anterior elevation
Preoperative anterior elevation was higher in the RCR group (86° (range, 36°–96°) vs 81° (range, 34°–87°)) (Table 6). Postoperative measurements (137° (range, 125°–147°) vs 129° (range, 119°–134°)) and improvement from the baseline (56° [range, 46°-91°] vs 43° [range, 34°-91°]) were greater in the control group. Again, the difference in improvement was greater than the MCID (−2.9°).
Table 6.
Anterior elevation. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Boileau (2009) | 65 | NA | 130 | NA | 65 | NA |
| Mulieri (2010) | 60 | 54 | 134 | 136 | 74 | 82 |
| Sadoghi (2011) | 36 | 34 | 127 | 125 | 91 | 91 |
| Shields (2017) | 93 | 84 | 127 | 130 | 34 | 46 |
| Patel (2020) | 73 | 77 | 119 | 127 | 46 | 50 |
| Dean (2022) | NR | NR | 124 | 137 | NA | NA |
| Marigi GHOA (2022) | 90 | 87 | 133 | 147 | 43 | 60 |
| Marigi CTA (2022) | 96 | 86 | 133 | 138 | 37 | 52 |
| Mean (range) | 86 (36–96) |
81 (34–87) |
129 (119–134) |
137 (125–147) |
43 (34–91) |
56 (46–91) |
CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; NA: not applicable; NR: not reported; RCR: rotator cuff repair.
Values are presented as mean; all measurements are in degrees.
Abduction
Preoperative abduction was higher in the RCR group (78° (range, 38°–86°) vs 69 (range, 36°–73°)) (Table 7). Postoperative measurements did not differ between the RCR group (121° (range, 118–131)) and control group (121° (range, 117°–125°)). Improvement from preoperative measurements was higher in the control group (52° (range, 46°–81°) vs 43° (range, 35°–80°)) and greater than the MCID (−1.9°).
Table 7.
Abduction. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Mulieri (2010) | 51 | 51 | 131 | 120 | 80 | 69 |
| Sadoghi (2011) | 38 | 36 | 118 | 117 | 80 | 81 |
| Patel (2020) | 66 | 71 | 113 | 117 | 47 | 46 |
| Marigi GHOA (2022) | 83 | 73 | 123 | 125 | 40 | 52 |
| Marigi CTA (2022) | 86 | 70 | 121 | 119 | 35 | 49 |
| Mean (range) | 78 (38–86) |
69 (36–73) |
121 (113–131) |
121 (117–125) |
43 (35–80) |
52 (46–81) |
CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; NA: not applicable; NR: not reported; RCR: rotator cuff repair.
Values are presented as mean, all measurements are in degrees.
External rotation
Preoperative (25° (range, 14°–34°) vs 19° (range, 14°–24°) and postoperative (37° (range, 14°–57°) vs 36° (range, 14°–47°)) external rotations were higher in the RCR group (Table 8). Improvement from preoperative levels (17° (range, 0°–27°) vs 11° (range, 0°–23°)) was higher in the control group and greater than the MCID (−5.3°).
Table 8.
External rotation. a
| Study | Preoperative | Postoperative | Mean difference | |||
|---|---|---|---|---|---|---|
| RCR | Control | RCR | Control | RCR | Control | |
| Mulieri (2010) | 34 | 20 | 57 | 47 | 23 | 27 |
| Sadoghi (2011) | 14 | 14 | 14 | 14 | 0 | 0 |
| Shields (2017) | 27 | 24 | 28 | 29 | 1 | 5 |
| Patel (2020) | 18 | 16 | 28 | 29 | 10 | 13 |
| Dean (2022) | NR | NR | 45 | 45 | NA | NA |
| Marigi GHOA (2022) | 25 | 15 | 41 | 39 | 16 | 24 |
| Marigi CTA (2022) | 28 | 21 | 37 | 37 | 9 | 16 |
| Mean (range) | 25 (14–34) |
19 (14–24) |
37 (14–57) |
36 (14–47) |
11 (0–23) |
17 (0–27) |
CTA: cuff tear arthropathy; GHOA: glenohumeral osteoarthritis; NA: not applicable; NR: not reported; RCR: rotator cuff repair.
Values are presented as mean; all measurements are in degrees.
Complications
Perioperative and postoperative complications were stratified by RCR status in seven studies (64%) (Table 9).22,23,27,28,31,32 The overall complication rate was 8% (range, 3%–17%) in the RCR group and 5% (range, 2%–15%) in the control group. Among studies outlining specific complications, the most common were infection, instability/dislocation, and fracture for both the RCR and control groups. One of the included studies specifically identified patients that developed periprosthetic infections, 28 while another analyzed long-term survivorship and the need for revision surgery. 22 Among the studies stratifying complications by prior RCR status,23,27,28,30–32 a total of 4 (0.5%) infections (range, 0%–5%) were reported in the RCR group and 19 (1.2%) in the control group (range, 0%–4%). The revision rate was 3% (range, 1%–10%) in the RCR group and 1% (range, 1%–10%) in the control group. The most common reason for revision in the RCR group was component loosening and shoulder instability/dislocation in the control group. Interestingly, only one study stratifying the need for revision by prior RCR status cited infection as the indication for revision. 27 Only three studies (27%) reported on scapular notching and stratified results by RCR status.23,27,31 Among these studies rates of scapular notching varied between 1% and 35% in the RCR group and 0% to 38% in the control group.
Table 9.
Complications and reoperation. a
| Study | Complication percentage | Complication detail | Revision percentage | |||
|---|---|---|---|---|---|---|
| RCR (%) | Control (%) | RCR (n) | Control (n) | RCR (%) | Control (%) | |
| Sadoghi (2011) | 14 | 10 | Paresthesia of the radial nerve (1) Stem loosening (3) |
Glenoid luxation (4) | 10 | 10 |
| Morris (2015) | 4 | 5 | Periprosthetic joint infection (1) | Periprosthetic joint infection (14) | - | - |
| Shields (2017) | 12 | 11 | Intraoperative anterior glenoid rim fracture (1) Postoperative acromial fracture (1) Postoperative scapular spine fracture (1) Dislocation (1) DVT (1) Cardiomyopathy (1) Radiculopathy (2) Perineural catheter site infection (1) Polyethylene dissociation (1) |
Intraoperative greater tuberosity fracture (1) Intraoperative humeral fracture (3) Postoperative humeral shaft fracture (1) Postoperative acromial fracture (1) Dislocation (4) Myocardial infarction (1) Renal artery thrombosis (1) Pneumonia (1) Clostridium difficile infection (1) Instrument complication (3) Ulnar nerve palsy (1) Superficial cellulitis (1) Repeat dislocation (2) Polyethylene dissociation (1) |
1 | 1 |
| Patel (2020) | 8 | 15 | Axillary nerve palsy (1) Implant loosening (1) Postoperative acromial fracture (2) Periprosthetic humeral fracture (2) |
Intraoperative fracture (2) Polyethylene dissociation (1) Acromial fracture (1) Periprosthetic humeral fracture (3) Deep infection (2) Wound dehiscence (1) Dislocation (1) |
1 | 3 |
| Chelli (2022) | 12 | - | - | - | 3 | - |
| Dean (2022) | 17 | 4 | Shoulder instability (9) Stress fractures (2) Notching (1) Infection (2) DVT (1) |
Shoulder instability (3) Infection (1) |
5 | 1 |
| Marigi (2022) | 3 | 2 | Fracture (4) Infection (1) Instability/dislocation (3) Pain/stiffness (2) Nerve injury (1) Aseptic loosening (3) |
Glenosphere dissociation (4) Fracture (7) Infection (2) Pain/stiffness (4) Instability/dislocation (3) |
2 | 1 |
| Mean (range) | 8 (3–17) |
5 (2–15) |
3 (1–10) |
1 (1–10) |
||
DVT: deep vein thrombosis; RCR: rotator cuff repair.
- indicates not reported or could not be determined from available data.
Discussion
This systematic review demonstrates that although patients with a history of prior RCR experience clinically relevant improvements from the baseline, weighted mean functional and subjective outcome scores may be lower compared with patients with no history of prior RCR. Specifically, compared with controls, patients with prior RCR reported lower postoperative PROs, exhibited less improvement in ROM measurements, and experienced higher rates of complication and revision. However, the differences in subjective PROs may be below clinically significant thresholds.
Multiple studies have attempted to define the MCID for a variety of PROs after RSA including the ASES, Constant, SST, and VAS-pain scores.37–42 For both RCR and control groups, improvement in ASES, Constant, SST, and VAS-pain scores exceeded all MCID thresholds. When comparing postoperative PROs and improvement from the baseline between the two groups, the differences were all below the MCID. These findings suggest that both groups derive clinical benefit from RSA and that the trend toward lower outcomes among the RCR group may not be of clinical relevance. This nuance is important to acknowledge as it directly relates to our understanding of prior RCR as a risk factor for poor outcomes. Ultimately, the decision to pursue RCR surgery should be made independently of the potential need for future RSA. However, with an understanding of the influence of prior RCR on RSA outcomes, surgeons will be better suited to counsel patients regarding postoperative expectations should RSA become indicated.
While the differences in PROs observed in this study were below the MCID, among individual studies reporting a difference, potential contributors to lower outcome scores with prior RCR have been suggested. Shields et al. proposed that although relatively uncommon, low rates of deltoid detachment and atrophy after RCR could contribute to inferior outcomes in larger cohorts, as atrophy and fatty infiltration have both been shown to be risk factors for poor functional outcomes after RSA.32,43,44 Additional explanation included postoperative scarring and psychological factors.
Although the MCID was first described in relation to PROs, the concept has been expanded to functional outcomes including ROM.36,40 In the context of RSA, Simovitch et al. have defined the MCID for external rotation, anterior elevation, and abduction to be −5.3°, −2.9°, and −1.9°, respectively. 40 These findings reflect the idea that small changes in ROM result in clinically meaningful improvement and that restoration of ROM may be less of a priority relative to other factors such as pain, stability, and rates of complication. 40 Improvement in postoperative ROM from the baseline was well above the defined thresholds for both cohorts. Additionally, the difference in improvement between cohorts was above the MCID for all measurements suggesting less improvement in the prior RCR group. It should be noted that preoperative ROM was higher in the RCR across all measurements and that the differences in improvement could be due to a potential ceiling effect. Because patients undergoing RSA may only achieve an upper limit on select outcomes, those with a higher baseline will likely demonstrate less improvement.45–47 Slight differences in indication such as a higher proportion of CTA, pseudoparalysis, and osteoarthritis in the control group compared with massive RCT or tear progression without osteoarthritis could also explain observed differences. Alternatively, Marigi et al. proposed that patients with prior RCR may have greater rates of superior rotator cuff tearing at the time of RSA which would theoretically result in less synergistic power for overhead elevation to assist the deltoid. 27
Despite favorable functional outcomes and pain relief, complication rates after RSA remain a topic of concern. Prior shoulder surgery has been reported as a risk factor for complications after RSA including prosthesis infection and instability with additional concerns regarding the need for short- to mid-term revision in younger patients.28,48,49 Other studies have reported no increase in complications and made the conclusion that soft tissue reconstruction likely does not significantly increase the risk of adverse events postoperatively.27,31,32 Overall, the complication rate was slightly higher in the RCR group compared with controls with no difference in the most frequent type of complications. Among studies outlining specific complications, the most common were infection, instability/dislocation, component loosening, and fracture for both the RCR and control groups. These results are consistent with a review of 21 cohort studies published by Zumstein et al. which found the most common postoperative complications after RSA to be instability (6.9%), infection (5.6%), and glenoid loosening (5.0%). Importantly, no study reported a significantly higher rate of infection among the RCR group and overall rates of infection were similar regardless of RCR status. The authors reported a cumulative incidence of intra- and postoperative humeral, glenoid, scapular, and acromion fractures of 8.6% which explains the relative predominance of fractures in this review. Despite the trend toward a higher complication rate in the RCR group, because reported rates ranged from 3% to 17% in the RCR group and 2% to 15% in the control group, the difference of 3% is of questionable significance.
The most common reason for revision in the RCR group was glenoid or humeral component loosening and shoulder instability/dislocation in the control group. In a review article published by Boileau et al., the most common reasons for revision in a series of 825 RSAs were, in decreasing order, prosthesis instability (38%), infection (22%), humeral implant complications (21%), and glenoid implant complications (13%). 50 Interestingly, the only study to site infection as the indication for revision and stratify results by RCR status was the study authored by Marigi et al. 27 With revision rates ranging from 1% to 10% in both RCR and control groups, no definitive conclusions can be made regarding the risk of revision despite a trend toward a higher rate of revision in the RCR group (3% vs 1%).
This review is not without limitation. First, the quality of this review is dependent on the quality of the individual studies from which data were extracted. None of the included studies were level I evidence, but rather level II–IV only. While 1 study was prospective in nature, the remaining 10 were retrospective which inherently increases the risk of selection and recall biases. Furthermore, due to inconsistencies in the reporting of variance associated with outcome measures, a formal meta-analysis utilizing inverse-variance weighting could not be performed. Rather, data were pooled and weighted utilizing the sample size to highlight relevant trends. Additionally, because the goal of this review was to provide an overview of outcomes of RSA after prior RCR, studies reporting on the influence of prior surgery but not stratifying outcomes by prior RCR status were excluded. Even among included studies not all results, such as complications, were stratified by prior RCR status. These studies inevitably included patients with prior RCR, but their inclusion would have introduced an additional layer of undesired heterogeneity. It should also be noted that due to limitations in the manner data were reported, patients could not be stratified on the basis of prior open versus arthroscopic RCR. This is important to consider as one could assume that patients with previous open RCR may have poorer deltoid function or weakness leading to reduced ROM. Additionally, although the concept of MCID has been well studied and provides valuable insight into the clinical relevance of reported data, the ROM MCID values reported in the literature and utilized in this study likely fall within the margin of error for measurement, thus limiting their relevance and overall utility. Lastly, due to the granularity with which data were reported, mean follow-up between cohorts could not be compared. Although two years is generally considered appropriate follow-up for RSA procedures, it is important to consider the potential influence of differences in follow-up as the outcomes of RSA may evolve over time.
Conclusion
Patients undergoing RSA after prior RCR demonstrate improvements in functional and subjective outcomes. Compared with patients without prior RCR, among patients with prior RCR, improvements in ROM from the baseline are lower. Differences in postoperative PROs and improvement from the baseline demonstrate a trend toward lower outcomes in patients with prior RCR but may be below the MCID.
Footnotes
Author contribution: All eight authors meet full four-point ICMJE criteria for authorship.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Bryan M. Saltzman https://orcid.org/0000-0003-3984-4246
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