Summary

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.

Abstract

Objectives:
Surgical indications for massive, irreparable rotator cuff tears (RCT) without arthritis remain unclear. The purpose of this study was to compare 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 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 and have intra-op confirmation of a massive, irreparable, RCT without arthritis. Patient demographics and pre-op clinical findings were collected. Post-op data included complications, patient satisfaction, strength and ROM, and patient reported outcomes. Multivariate analysis was also performed.

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). Intra-op 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). Pseudoparalysis was present in 18.8% of SCR, 0% of PR, and 14.3% of rTSA patients (p=0.08).

All groups saw significant post-op improvement in strength and patient reported outcomes (p<0.036). SCR and rTSA demonstrated improved forward elevation ROM post-op while PR did not (p=0.96). No group experienced improvement in IR or ER ROM post-op (p>0.12). rTSA had significantly worse post-op ROM in all planes compared to SCR and PR (p<0.003 for all). There were no differences between groups in post-op strength (p>0.16) 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). Three 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 3 surgical complications among 42 rTSA patients (7.1%) (2 acromial stress fractures; 1 dislocation requiring open reduction). There were 4 non-surgical complications in the SCR group and 1 stroke in the rTSA group. One SCR patient and 3 rTSA patients were deceased. 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 (p=0.03) and strength (p=0.048). An increased AH interval distance was an independent predictor of improved post-op strength (p<0.02).

Conclusion

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.