Reverse shoulder arthroplasty for rotator cuff tears with and without prior failed rotator cuff repair: A large-scale comparative analysis

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

Background

Arthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and long-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature.

Methods

Patients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology codes. The exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched in a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. 1-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test.

Results

In total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354, respectively. Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (P < .0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (P < .0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery.

Discussion and Conclusion

Fibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in 1-year revisions.

What are we matching on and why? A systematic review of matched study designs in shoulder arthroplasty

BACKGROUND

Establishing patient-matched cohorts can be a valuable technique for minimizing selection bias in outcomes research pertaining to shoulder arthroplasty. This systematic review evaluated the variety and inconsistency with which matching techniques are employed in matched studies assessing outcomes following shoulder arthroplasty.

METHODS

The PubMed, EMBASE, and Cochrane computerized databases were queried from their inception through December 2023 to identify clinical outcome studies of shoulder arthroplasty that employed a matched study design. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Matching techniques, covariates included, and covariate justification were aggregated.

RESULTS

Among 110 studies encompassing 483,738 shoulder arthroplasties, 82 (74.6%) studies employed direct matching and 28 (25.5%) employed propensity score matching. Seventy-four distinct covariates were used in at least one study, with 86 unique combinations of covariates employed. Studies used a median of 4 covariates (range 1-27). The most common covariates were age (94.5%), sex (89.1%), body mass index (26.4%), smoking (19.1%), and follow-up duration (19.1%). Only 16 (14.6%) studies reported justification for the covariates included.

CONCLUSIONS

There are marked methodological discrepancies among studies using covariate matching methods in the shoulder arthroplasty literature. Future matched studies in shoulder arthroplasty should provide justification for included covariates and properly account for matching in their statistical analyses to enhance the validity of study findings. When patient matching is deemed appropriate, key variables to consider for matching may include patient age, sex, comorbidity burden and, when analyzing multiple clinical conditions, surgical indication.

Perioperative Losartan Is Associated With Similar Rates of Additional Surgical Procedures for Postoperative Shoulder Stiffness After Primary Arthroscopic Rotator Cuff Repair but Lower Rates of Secondary Debridement and Repair

PURPOSE

To compare the rate of additional shoulder surgery related to postoperative stiffness or tendon healing after primary rotator cuff repair between patients with a losartan prescription and without a losartan prescription.

METHODS

The International Classification of Diseases, Tenth Revision, code M75.1 was used to identify all patients in the TriNetX Research Network with a rotator cuff tear diagnosis who underwent arthroscopic rotator cuff repair between January 1, 2015, and December 31, 2021. Patients were stratified into the losartan group (LG) and nonlosartan group (NLG) on the basis of whether they had a coded prescription for losartan within 1 year before surgery or 3 months after surgery. The 2 cohorts were propensity scored and matched to reduce confounding biases. Specifically, cohorts were matched on the basis of age, gender, obesity, nicotine use, hyperlipidemia, diabetes, hypertensive diseases, ischemic heart disease, heart failure and valvular disease, and peripheral arterial disease. The incidence of additional shoulder surgeries associated with stiffness and rotator cuff healing was analyzed and compared at 1-year and 2-year time points.

RESULTS

After propensity score matching, both the LG and NLG contained 3,970 patients. There was no difference in the rate of lysis of adhesions or manipulation under anesthesia at 1-or 2-year postoperatively between patients in the LG and LG. Patients in the LG were less likely undergo arthroscopic debridement (odds ratio 0.71; confidence interval 0.56-0.91; P = .006) and rotator cuff repair (odds ratio 0.71; confidence interval 0.58-0.87; P = .001) 1-year postoperatively than patients in the NLG group. At 1-year postoperatively, there was no difference in the rate of arthroplasty, arthroscopic synovectomy, and diagnostic arthroscopy between groups. At 2-year postoperatively, there was no difference in the rate of rotator cuff repair, arthroplasty, arthroscopic debridement, synovectomy, and diagnostic arthroscopy between groups.

CONCLUSIONS

Patients undergoing arthroscopic rotator cuff repair with or without a perioperative prescription for losartan had no significant difference in the rate of lysis of adhesions or manipulation under anesthesia at 1- or 2-year postoperatively, indicating that the antifibrotic properties of losartan may not have a clinically significant impact on shoulder stiffness after arthroscopic rotator cuff repair. However, patients with a prescription for losartan were less likely to undergo additional arthroscopic debridement and rotator cuff repair 1-year postoperatively than a matched cohort of patients without a prescription for losartan.

LEVEL OF EVIDENCE

Level III, case control study.

Is the impact of previous rotator cuff repair on the outcome of reverse shoulder arthroplasty clinically relevant? A systematic review of 2879 shoulders

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.

Shoulder Arthroplasty After Previous Nonarthroplasty Surgery: A Systematic Review and Meta-Analysis of Clinical Outcomes and Complications

BACKGROUND

Many patients who undergo shoulder arthroplasty (SA) have had at least 1 nonarthroplasty shoulder surgery before the surgery. There is conflicting evidence regarding the effects of previous shoulder surgery on the outcome of SA. A systematic review was conducted to compare functional outcomes and complications between SA patients with and without prior non-SA surgery on the ipsilateral shoulder.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE/PubMed, Embase, Scopus, and Web of Science comprehensively from inception to January 2023. Based on 9,279 records reviewed, 26 comparative studies were included in the meta-analysis consisting of 5,431 shoulders with prior nonarthroplasty procedures (cases) and 55,144 shoulders without previous surgery (controls). Variables such as functional scores, complications, and range of motion were compared between cases and controls using Review Manager Software. In addition, subgroup analysis was conducted based on prior surgery type (rotator cuff repair [RCR], open reduction and internal fixation [ORIF], soft tissue repairs, and not specified) and type of SA (hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty [RTSA]). The results were presented as odds ratios (ORs) or standardized mean differences (SMDs).

RESULTS

Except for a higher rate of periprosthetic joint infection (PJI) in patients who had undergone previous arthroscopic surgery (OR, 2.58; 95% confidence interval [CI], 1.66-4.01; p < 0.01), a higher rate of complications was only observed in patients with previous ORIF. These complications included aseptic loosening (OR, 3.43; 95% CI, 2.14-5.50; p < 0.01), shoulder dislocation (OR, 2.25; 95% CI, 1.05-4.84; p = 0.04), overall complication (OR, 3.95; 95% CI, 2.38-6.55; p < 0.01), and revision (OR, 2.52; 95% CI, 1.28-4.97; p = 0.01). Patients with a history of previous surgery demonstrated inferior functional outcomes in comparison with the control group, including American Shoulder and Elbow Surgeons (SMD, -0.39; 95% CI, -0.51 to -0.27; p < 0.01; I2 = 36%), Constant-Murley score (SMD, -0.34; 95% CI, -0.44 to -0.24; p < 0.01; I2 = 0%), abduction (SMD, -0.26; 95% CI, -0.45 to -0.08; p = 0.01; I2 = 54%), and flexion (SMD, -0.33; 95% CI, -0.46 to -0.21; p < 0.01; I2 = 40%). Subgroup analysis by previous type of surgery was not possible regarding functional outcomes.

CONCLUSION

Patients who have had prior fracture surgery are at a higher risk of complications, reoperations, and revisions after SA than controls. The normal shoulder anatomy may be disrupted by prior surgery, which makes arthroplasty technically challenging, particularly when it comes to soft tissue balance. On the other hand, RCR before SA did not negatively affect clinical outcomes after RTSA and did not have a higher rate of overall complications (except PJI).

LEVEL OF EVIDENCE

Level III (Treatment Studies). See Instructions for Authors for a complete description of levels of evidence.