Abstract
Background
Loss of internal rotation remains an issue after reverse total shoulder arthroplasty (RTSA). Our goal is to define the expected functional internal rotation after RTSA using the Activities of Daily Living which require Internal Rotation (ADLIR) score in a homogenous population of patients treated with RTSA.
Methods
35 patients with a minimum follow-up of two years after RTSA were evaluated using the ADLIR and Constant-Murley questionnaires. A correlation between the ADLIR and Constant score was investigated and the internal validity of the ADLIR score used in a RTSA patient population was measured using Cronbach's alpha coefficient. The impact of internal rotation on the total rotational arc of motion was defined.
Results
Excellent results were recorded for both the Constant score (79 ± 18) and ADLIR score (88 ± 16). Pearson's correlation coefficient was r = 0,84 (p-value <0,001). The ADLIR score showed a high reliability for all questions.
Conclusions
The ADLIR score has proven to be a useful addition in the post-operative evaluation of patients treated with RTSA. Further studies are needed to investigate the evolution of the ADLIR score from pre- to postoperatively in order to determine the clinical and predictive value of this score.
Level of evidence
Level IV - Observational study.
Keywords: Reverse total shoulder arthroplasty, internal rotation, patient-reported outcome, Constant-Murley score, ADLIR score
Introduction
Since Grammont introduced the reverse total shoulder arthroplasty (RTSA) in the treatment of cuff tear arthropathy (CTA) and irreparable rotator cuff tears, very satisfying results have been described.1–3 Post-operative recovery of active forward elevation and active external rotation are (with or without the use of tendon transfers) routinely obtained and only mildly influenced by the implant type or surgical approach that has been used. 4 While recovery of forward elevation and external rotation are rather straightforward, recovery of active internal rotation has remained somewhat enigmatic. 5 Important activities of daily living such as personal hygiene and toileting can be affected by the loss of active internal rotation. 6 Different study groups have conducted extended research in order to define which parameters influence post-operative range of motion. 7
Post-operative active internal rotation seems correlated to disinsertion of the subscapularis tendon, non-concentric gleno-humeral osteoarthritis, low body mass index (BMI), at least 6 mm of glenosphere overhang, absence of excessive upwards orientation of the glenoid before surgery, and inferior glenosphere tilt.8–10
In order to monitor active internal rotation, the vertebral level is widely accepted as the gold standard of registration. Rojas et al. recently pointed out that the current measurement techniques reported in clinical RTSA literature are not adequate in order to accurately assess the effects of RTSA on IR. These measurement techniques should be accurate and reproducible in order to make meaningful comparisons between studies. 11 Furthermore, the functional impact of (deficient) internal rotation is more interesting than range of motion or internal rotation strength in itself. Aleem et al. proposed a simple Likert-type scale questionnaire consisting of 10 questions focusing on activities requiring active internal rotation. 12 Another functional self-reported outcome score assessing active internal rotation was proposed by the group of Werthel et al., the ADLIR-score. 13 This questionnaire was initially designed to asses long term results of latissimus dorsi transfers in patients with obstetric brachial plexus injuries and has previously been used to investigate the subjective internal rotation function in a patient population treated by combined RTSA and latissimus dorsi transfer. 4
We agree with the suggestions made by Rojas et al. and therefore changed our focus from purely measuring postoperative range of motion into measuring the functional impact of internal rotation using the ADLIR self-reported outcome score. We decided to determine the mean post-operative ADLIR-score in a patient population treated by RTSA at a minimum of two years follow up, with the purpose of being able to use the ADLIR-score prospectively in our future practice. We also correlated the ADLIR and Constant-Murley scores for this patient population, in which indication, prosthetic component fixation and surgical technique were homogenous.
Materials and methods
In order to evaluate and to estimate the expected outcome of the ADLIR self-reported outcome score in a homogenous cohort of patients treated by RTSA, 35 consecutively treated patients were evaluated. Basic patient demographics (age, sex, operative side), pre-operative diagnosis, previous surgical interventions, BMI, surgical approach, lateralization, retroversion of the humeral component and component size were registered for each patient. Each surgery was performed by one of two trained shoulder surgeons (LL or TL) using the Delta Xtend Reverse Shoulder System (DePuy Synthes, Warsaw, IN, USA). The subscapularis tendon was routinely released and never reinserted. Exclusion criteria comprised fracture sequellae, complex instability cases and revision prosthetic surgery.
The ADLIR questionnaire consists of nine questions. The first question is scored from ‘Significantly’ (six points) to ‘Not at all’ (20 points). Questions two to nine are scored from ‘Impossible’ (one point) to ‘Not difficult’ (ten points) in a Likert-scale fashion. A maximum score of 100 points indicates that the patient has no impairment in his or her daily life due to a limitation in internal rotation. A minimum score of 14 indicates severe functional impairment due to limited internal rotation. 13 The age and sex adjusted Constant score was determined as described by Chelli et al. 14 Total ADLIR scores and individual scores per question were registered. The Pearson correlation coefficient (PCC) was used to determine the relation between the ADLIR and Constant scores. Cronbach's alpha coefficient was used to measure the internal consistency of the ADLIR score.
The total rotational arc of motion was defined by combining internal and external rotation outcomes, obtained from the clinical evaluation, as described in Table 1. Data collection and statistical analysis were performed using IBM SPSS Statistics for Macintosh (Version 27.0 Armonk, NY: IBM Corp.) software.
Table 1.
Rotational arc of motion scoring.
| External rotation scoring | |
|---|---|
| 1 | Hands behind head, elbows forward |
| 2 | Hands behind head, elbows back |
| 3 | Hands to the top of the head, elbows forward |
| 4 | Hands to the top of the head, elbows back |
| 5 | Full elevation of the arms |
| Internal rotation scoring | |
| 1 | Lateral aspect of the thigh |
| 2 | Behind the buttock |
| 3 | Sacroiliac joint |
| 4 | Waist |
| 5 | 12th thoracic vertebra |
| 6 | Interscapular level |
Investigations were conducted according to the 1964 Declaration of Helsinki ethical standards as revised in 2013 and to the MR-003 reference methodology. 15 The study was registered in the CNIL database register (No. 2220602) and the patients were informed and consented before any data collection and/or analysis.
Results
35 patients with a mean age at intervention of 72 ± 6 years were evaluated at a minimum of two years postoperatively (mean 33 ± 5 months) after RTSA. Mean post-operative ADLIR score was 88 ± 16, mean Constant score was 79 ± 18. Mean post-operative forward elevation was 152° ± 25°, rotational arc of motion was registered as described in Table 1 and presented in Figure 1.
Figure 1.
Rotational arc of motion. Y-axis refers to the rotational arc of motion scoring as defined in Table 1
ER, external rotation; IR, internal rotation.
An excellent correlation was found between the ADLIR and Constant scores (Figure 2) with a Pearson's Correlation Coefficient r = 0,84 (p-value <0001). Cronbach's alpha score was calculated for the entire questionnaire and for the questionnaire if a certain question was removed. With a Cronbach's alpha coefficient of 0,88 the ADLIR questionnaire can be considered very reliable. Table 2 shows the Cronbach's alpha coefficient if a question was removed. Removing a single question did not improve nor decrease the reliability of the questionnaire. For this limited population, no significant relationship could be observed between the ADLIR or Constant scores and component lateralization, component sizing, BMI and adjusted retroversion of the humeral component.
Figure 2.
Correlation between constant-murley and ADLIR score.
Table 2.
Assessment of questionnaire reliability using Cronbach's Alpha.
| Question 1 excluded | 0.92 |
| Question 2 excluded | 0.86 |
| Question 3 excluded | 0.87 |
| Question 4 excluded | 0.84 |
| Question 5 excluded | 0.84 |
| Question 6 excluded | 0.85 |
| Question 7 excluded | 0.85 |
| Question 8 excluded | 0.85 |
| Question 9 excluded | 0.87 |
Discussion
Functional scores
The results of this study support the ADLIR score as described by the research group of Werthel et al. as an appropriate method to asses functional internal rotation for patients treated with RTSA. 13 The popularity of this intervention is rapidly expanding, therefore, the need for thorough clinical follow-up remains imperative. Since internal rotation has always been the Achilles heel for RTSA patients, a self reported outcome score to asses functional internal rotation was deemed useful in addition to the Constant-Murley score.
The mean post-operative Constant score was high and comparable to earlier reported Constant scores after RTSA. 16 This confirms the value of this intervention for the before-mentioned indications. A high correlation was found between the ADLIR and Constant-scores. The excellent ADLIR scores at a minimum of two years postoperatively suggest an adequate functioning in internal rotation after RTSA. BMI and individualized humeral retroversion have been identified as independent predictors of IR but these observations could not be confirmed nor refuted for our patient population.17,18
The subscapularis tendon
Biomechanic and functional implications of subscapularis tendon repair have been investigated thoroughly in patients treated with reverse total shoulder arthroplasty.18–20 Whether to repair the subscapularis tendon or not remains an interesting topic in the field of reverse total shoulder arthroplasty. Friedman et al. reported excellent outcomes after RTSA for both patients with and without subscapularis repair with a follow-up comparable to this present study. 8 For every patient included in our study, a subscapularis tenotomy was performed during the intervention. Despite for this cohort of patients the subscapularis tendon has not been repaired, they achieved high scores for activities of daily living requiring active internal rotation.
Rotational arc of motion
A functional post-operative arc of motion is needed in order to perform regular activities of daily living. Earlier cadaveric studies have focused on the impact of humeral version on impingement-free range of motion in RTSA.12,21 The version of the humeral implant for every patient in our population was between 20° and 30° of retroversion, in order to approach the most optimal rotationally balanced RTSA.21,22 This concept is important because improvement in internal rotation should not impair remaining external rotation leading to worse clinical outcomes. The rotational arc of motion results suggest that improved post-operative internal rotation does not negatively affect the remaining external rotation. On the contrary, the results displayed in Figure 1 support an association between superior IR and superior ER, confirming the findings of Wirth et al. 22 Further prospective research will be needed to confirm the value of this concept and the implications of its use in daily practice.
Future research
This pilot study has shown that the ADLIR score can effectively be used in the follow-up of patients treated by RTSA. Comparing the pre-operative ADLIR score to the mean expected outcome - defined in this study - will help surgeons in their decision making process and may be valuable to predict the impact of surgery. It can also be used as a tool in order to compare the impact of different implants and surgical techniques on functional post-operative IR.
Limitations
This study displays the results of a recently described patient-reported outcome measure, used in a homogenous patient population of patients treated with RTSA. The limited amount of included patients is the main limitation. The high correlation coefficient and statistical significance however show that the main hypothesis of this study could be confirmed. The ADLIR scores were not recorded pre-operatively since this pilot study is a part of a greater research project in which ADLIR scores will be recorded prospectively in order to be able to follow up these scores for individual patients at pre- and post-operative evaluation moments and to distinguish the impact of adjusted surgical techniques and prosthetic components on active internal rotation.
Conclusion
The ADLIR score is an accessible questionnaire that can be used to monitor functional internal rotation following RTSA. It can be used in addition to other patient reported outcome measures and shoulder specific scores in order to better assess postoperative results. Further prospective research will shed light on the value and clinical impact of the ADLIR score in the population of patients treated with RTSA.
Acknowledgements
We would like to thank Lydie Reisenthel for her assistance in this research project.
Footnotes
Contributorship: All authors contributed to the study conception and design. Material preparation and data collection were performed by JB, GC, LK, PC and SM and analysis were performed by JB, LL and TL. The first draft of the manuscript was written by JB and all authors reviewed previous versions of the manuscript. All authors read and approved the final manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship and/or publication of this article.
Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. This study has been approved by the Commission Nationale Informatique & Libertés. Reference number: 2220602v0
Informed Consent: Written informed consent was obtained from all individual participants included in the study, prior to data recording and data analysis.
ORCID iD: Joris J Beckers https://orcid.org/0000-0002-4390-0469
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