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Arthritis Severity and Medical Comorbidities Are Prognostic of Worse Outcomes Following Arthroscopic Rotator Cuff Repair in Patients With Concomitant Glenohumeral Osteoarthritis

Open AccessPublished:October 06, 2022DOI:https://doi.org/10.1016/j.asmr.2022.08.005

      Purpose

      To assess demographic factors, comorbidities, radiographic variables, and injury patterns as potential prognostic indicators of poor functional and patient-reported outcomes following arthroscopic rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.

      Methods

      A retrospective review of consecutive patients with glenohumeral osteoarthritis who underwent arthroscopic supraspinatus repairs between 2013 and 2018 with a minimum of 1-year follow up was performed. Demographic variables included age, tobacco use, alcohol use, diabetes, sex, hypercholesterolemia, and body mass index while injury patterns included partial- versus full-thickness tear, bicep tendon involvement, and osteoarthritis severity. Multivariate linear regression was used to identify independent predictors of visual analog pain scale (VAS), subjective shoulder value (SSV), and American Shoulder and Elbow Surgeons (ASES) score as well as active range of motion (ROM) in forward flexion (FF) and external rotation (ER). Binary logistic regression was used to identify predictors of repair failure as well as postoperative strength in FF and ER.

      Results

      In total, 91 patients (mean age 61.48 ± 9.4 years) were identified with an average follow up of 26.3 ± 5.7 months. Repair failures occurred in 9.9% (9/91 patients) of the total cohort. Postoperative outcomes were significantly improved with regards to visual analog pain scale, subjective shoulder value, ASES score, ROM in FF, FF strength, and external rotation strength compared with preoperative baseline. Obesity (P = .023) and diabetes (P = .010) were significant independent predictors of greater pain scores postoperatively. Obesity (P = .029) and tobacco use (P = .007) were significant predictors of lower ASES scores postoperatively. Finally, moderate-to-severe osteoarthritis was a significant risk factor for poor ROM and strength in FF postoperatively compared to mild osteoarthritis (P = .029). No variables were predictive of repair failure.

      Conclusions

      Tobacco use, obesity, and diabetes are associated with worse pain and patient-reported outcomes following arthroscopic rotator cuff repair in the context of glenohumeral OA. In addition, moderate-to-severe OA is associated with worse strength and forward flexion compared to those with mild OA.

      Level of Evidence

      Level III, retrospective cohort study.
      Glenohumeral osteoarthritis (OA) is a common degenerative pathology,
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      Prevalence of and risk factors for shoulder osteoarthritis in Japanese middle-aged and elderly populations.
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      Management of rotator cuff tears in patients with concomitant glenohumeral OA varies and is still debated. Treatment may be dependent on the degree of shoulder OA and the size of the rotator cuff tear. For those with mild OA and partial rotator cuff tears, treatment often is initiated with conservative management, including physical therapy and steroid injections.
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      For those with severe OA and larger rotator cuff tears, reverse or anatomic total shoulder arthroplasty has been shown to have favorable outcomes.
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      However, recent studies have demonstrated good-to-excellent outcomes following arthroscopic rotator cuff repair in the setting of glenohumeral OA.
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      Optimal management of glenohumeral osteoarthritis.
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      The effect of glenohumeral osteoarthritis on the outcome of isolated operatively treated supraspinatus tears.
      ,
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      Arthroscopic management of glenohumeral arthritis.
      Studies comparing rotator cuff repair (RCR) in patients with glenohumeral OA with those without have shown no difference in repair failure rates.
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      • Lin A.
      Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.
      In addition, one study found no differences in range of motion (ROM), strength, or patient-reported outcomes between the 2 groups,
      • Jeong H.Y.
      • Jeon Y.S.
      • Lee D.K.
      • Rhee Y.G.
      Rotator cuff tear with early osteoarthritis: How does it affect clinical outcome after large to massive rotator cuff repair?.
      whereas others found slightly lower postoperative ROM among patients with glenohumeral OA.
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      • Min S.G.
      • Lee H.S.
      • et al.
      Clinical outcome of rotator cuff repair in patients with mild to moderate glenohumeral osteoarthritis.
      ,
      • Reddy R.P.
      • Solomon D.A.
      • Hughes J.D.
      • Lesniak B.P.
      • Lin A.
      Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.
      Few studies, however, have evaluated the subset of patients in this population who would benefit most from RCR. Risk factors for poor outcomes of RCR in patients presenting with concomitant glenohumeral OA have not been established. Identifying the risk factors for poor outcomes may promote optimal patient selection and would allow for more informative pre- and postoperative patient counseling.
      The purpose of this study was to assess demographic factors, comorbidities, radiographic variables, and injury patterns as potential prognostic indicators of poor functional and patient-reported outcomes (PROs) following arthroscopic RCR in patients with concomitant glenohumeral OA. We hypothesized that tobacco use, obesity, diabetes, and increased severity of OA would be predictive of diminished patient-reported/functional outcomes and repair failure.

      Methods

      Study Design and Patient Collection

      This was a retrospective cohort study that reviewed electronic medical records of patients with glenohumeral OA who underwent a primary RCR performed by 2 fellowship-trained orthopaedic sports medicine surgeons from 2013 to 2018. Institutional review board approval was obtained at the University of Pittsburgh for this retrospective chart review, STUDY20030061. A waiver of consent was granted by the institutional review board at the University of Pittsburgh. Inclusion criteria were patients older than 30 years of age with concomitant glenohumeral OA and supraspinatus tear (both partial- and full-thickness tears as well as with concomitant infraspinatus/subscapularis tears), who underwent primary arthroscopic surgical repair and had a minimum of 1-year postoperative follow-up data. Exclusion criteria included previous RCR, open RCR, previous infection of symptomatic shoulder, and insufficient follow-up data. The patient outcomes reported in this study are from the same cohort as one used in a previously published study by Reddy et al.
      • Reddy R.P.
      • Solomon D.A.
      • Hughes J.D.
      • Lesniak B.P.
      • Lin A.
      Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.

      Demographic Variables and Injury Patterns

      Baseline demographic variables of age, body mass index (BMI), and sex were recorded, along with several comorbidities, including diabetes, hypercholesterolemia, alcohol use, and tobacco use. Age was analyzed as a continuous variable whereas obesity (BMI >30), sex, diabetes, alcohol/tobacco use, and hypercholesterolemia were analyzed as nominal bimodal variables.
      Injury characteristics including partial- versus full-thickness tear, tear size, Goutallier classification, bicep tendon involvement, and severity of OA (mild vs moderate-to-severe) were also collected based on preoperative imaging and corroborated by intraoperative assessment. All high-grade partial-thickness tears (defined as >50% tearing of the footprint confirmed on intraoperative assessment) were completed to full tears and then repaired.
      Severity of OA was classified by a musculoskeletal radiologist using radiographic parameters according to the Samilson-Prieto classification modified by Gerber,
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      • Cakir B.
      • Reichel H.
      • Kappe T.
      Reliability of radiologic glenohumeral osteoarthritis classifications.
      ,
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
      which classifies arthrosis into 4 grades (normal, mild, moderate, and severe) based on size of humeral/glenoid exostosis and joint narrowing. Moderate and severe OA were combined into one category because those with moderate-to-severe OA could potentially be candidates for shoulder arthroplasty whereas patients with mild OA would be more likely to be managed with more conservative or joint-preserving options. Arthroscopic RCR was pursued in these patients because they were felt to have symptoms consistent with primary rotator cuff pathology but also had background OA noted on imaging, which was either asymptomatic or causing mild mechanical pain.

      Outcomes

      Primary outcomes included PROs of subjective shoulder value (SSV), visual analog pain scale (VAS), and American Shoulder and Elbow Surgeons (ASES) score; active (ROM) outcomes in forward flexion (FF) and external rotation (ER); as well as strength outcomes in FF and ER.
      The secondary outcome was failure of repair, defined as a symptomatic retear confirmed on postoperative magnetic resonance imaging (MRI). Postoperative MRI, however, was not standard protocol for all patients in the study but rather for those with suspected symptomatic failure. These patients returned to clinic postoperatively complaining of recurring pain and were subsequently found to have imaging confirming re-tear.
      All preoperative primary outcomes were determined at the last clinic visit before surgery and all postoperative primary outcomes were determined at the 12-month or final follow-up clinic visit postoperatively. Shoulder ROM and strength was assessed at 12 months’ postoperatively.
      FF and ER ROM were measured in their respective planes and strength testing was conducted with manual muscle grading from 0 to 5 based on previously validated methodology, with a 5 representing maintained muscle activation against examiner’s full resistance, a 4 representing muscle activation against examiner’s partial resistance, and a 3 representing muscle activation only against gravity or with no examiner resistance.
      • Williams M.
      Manual muscle testing, development and current use.
      FF strength was tested with the patient in a standing position with the shoulder flexed to 90° in the scapular abduction plane. ER strength was tested with the elbow in 90° of flexion and the shoulder in a neutral position.
      A follow-up period of 1 year was used because multiple studies have shown that most RCR outcomes achieve the minimal clinically important difference (MCID) at 6 months postoperatively, with a much lower proportion achieving the MCID at 1 year.
      • Manderle B.J.
      • Gowd A.K.
      • Liu J.N.
      • et al.
      Time required to achieve clinically significant outcomes after arthroscopic rotator cuff repair.
      ,
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      • van Noort A.
      • Sierevelt I.N.
      Quantifying the minimal and substantial clinical benefit of the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand score in patients with calcific tendinitis of the rotator cuff.
      The MCID for VAS ranges from 1.5 the 2.4, whereas the MCID for ASES ranges from 11.1 the 27.1.
      • Kim D.M.
      • Kim T.H.
      • Kholinne E.
      • et al.
      Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after arthroscopic rotator cuff repair.
      • Tashjian R.Z.
      • Shin J.
      • Broschinsky K.
      • et al.
      Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair.
      • Cvetanovich G.L.
      • Gowd A.K.
      • Liu J.N.
      • et al.
      Establishing clinically significant outcome after arthroscopic rotator cuff repair.
      Although the MCID for SSV following RCR is unknown, a value of 26.6 can be extrapolated from other pathologies.
      • Su F.
      • Allahabadi S.
      • Bongbong D.N.
      • Feeley B.T.
      • Lansdown D.A.
      Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state of outcome measures relating to shoulder pathology and surgery: A systematic review.
      ,
      • van de Water A.T.M.
      • Shields N.
      • Davidson M.
      • Evans M.
      • Taylor N.F.
      Reliability and validity of shoulder function outcome measures in people with a proximal humeral fracture.
      Regarding functional outcomes, ER is also typically regained within 1 year and FF is often restored by 3 months for small tears and 6 months for medium to large tears.
      • Harris J.D.
      • Ravindra A.
      • Jones G.L.
      • Butler R.B.
      • Bishop J.Y.
      Setting patients’ expectations for range of motion after arthroscopic rotator cuff repair.
      Furthermore, a vast majority of repair failures occur within 6 months of surgery.
      • Iannotti J.P.
      • Deutsch A.
      • Green A.
      • et al.
      Time to failure after rotator cuff repair: A prospective imaging study.

      Postoperative Rehabilitation Protocol

      Postoperative rehabilitation was standardized for all patients. All patients were fitted with a sling for 4 weeks postoperatively. Physical therapy was initiated at 2 weeks postoperatively starting with passive ROM exercises, including passive FF, passive ER, and pendulums as tolerated. Active ROM exercises as well as active-assisted exercises were gradually initiated at 6 weeks postoperatively as tolerated. Finally, shoulder-strengthening exercises were introduced starting at 12 weeks.

      Statistical Analysis

      Univariate analyses were conducted using either independent samples t test, χ2 analysis, Mann–Whitney U test, or Fisher exact test. Multivariate linear regression modeling was used to identify risk factors for poor outcomes regarding VAS, SSV, and ASES score as well as active ROM in FF, ER, and internal rotation. Binary logistic regression analysis was used to identify predictors of operative failure following RCR as well as postoperative strength in FF, ER, and internal rotation.
      Independent variables included in the regression analyses were demographic characteristics of age, tobacco use, alcohol use, diabetes, sex, hypercholesterolemia, and obesity (BMI ≥30 vs BMI <30); and injury characteristics of tear size (partial vs full-thickness tear), bicep tendon involvement, and severity of OA (mild vs moderate-to-severe) characterized by the Samilson-Prieto classification. Significance level was set to P < .05.
      A power analysis was performed. Given the cohort sample size, this study was able to achieve 89% power to detect an effect size of 0.5 with an alpha is 0.05 using a multiple linear regression analysis for VAS.

      Results

      Patient Demographics and Comorbidities

      A total of 232 patients who underwent primary arthroscopic RCR of a supraspinatus tear were reviewed, of whom 112 had concomitant glenohumeral OA. Of these 112 patients, 19 were excluded due to insufficient follow-up and 2 were excluded as they were revision repairs. The remaining 91 patients had 1-year follow up and met the remaining inclusion criteria to be included in the analysis. The resulting cohort had an average age of 61.48 ± 9.4 years and an average follow-up of 26.3 ± 5.7 months from initial surgery date. Of the 91 patients, 46 were male (50.5%), 14 used tobacco products (15.4%), 43 consumed alcohol (47.3%), 14 were diabetic (15.4%), and 28 (30.8%) had hypercholesterolemia. Average BMI was 30.9 ± 4.6, with 40.7% classified as having obesity (BMI ≥30). The demographic variables are detailed in Table 1.
      Table 1Demographic Data for Study Cohort
      Demographic VariableGH Arthritis (n = 91)
      Age, y61.48 ± 9.4
      BMI30.9 ± 4.6
      Sex (male)46 (50.5%)
      Diabetes14 (15.4%)
      Tobacco use14 (15.4%)
      Alcohol use43 (47.3%)
      Hypercholesterolemia28 (30.8%)
      Average follow-up, mo26.3 ± 5.7
      NOTE. Data are reported as n (%) unless otherwise specified.
      BMI, body mass index; GH, glenohumeral.

      Injury Patterns

      Of the 91 patients, 57 patients experienced a full -thickness tear of the supraspinatus (62.6%), whereas 34 patients had partial-thickness tears of the supraspinatus (37.4%) with an overall mean tear size of 15.5 mm. The Goutallier classification of the supraspinatus tendons was as follows: 45% grade 0, 13.2% grade 1, 19.8% grade 2, 5.5% grade 3, 5.5% grade 4, and 11% unspecified. Goutallier classification were similar between patients with and without obesity (grade 0: 49.0% vs 53.3%; grade 1: 17.6% vs 10.0%; grade 2: 19.6% vs 26.7%; grade 3: 5.9% vs 6.7%: and grade 4: 7.8% vs 3.3%; P = .758). Based on the Samilson–Prieto classification radiologically, 70 patients had mild OA (76.9%), whereas 21 had moderate-to-severe OA (23.1%). Finally, 63.5% of the patients had concomitant bicep tendon pathology as well. Injury and repair patterns are shown in Table 2.
      Table 2Injury Patterns and Treatment Variables for Study Cohort
      Clinical VariableGH Arthritis (n = 91)
      Single-row repair17/79 (21.5%)
      Double-row repair62/79 (78.5%)
      Partial thickness34 (37.4%)
      Full thickness57 (62.6%)
      Mild OA70 (76.9%)
      Moderate-to-severe OA21 (23.1%)
      Tear size, mm (range)15.5 (6-45)
      Nonpathologic biceps33/88 (37.5%)
      Goutallier classification
       Grade 041(45.0%)
       Grade 112 (13.2%)
       Grade 218 (19.8%)
       Grade 35 (5.5%)
       Grade 45 (5.5%)
       Unspecified10 (11.0%)
      Biceps procedures
       None47/91 (51.6%)
       Arthroscopic tenodesis17/91 (18.7%)
       Open tenodesis9/91 (9.9%)
       Tenotomy18/91 (19.8%)
      GH, glenohumeral; OA, osteoarthritis.

      Preoperative Baseline

      Preoperative PROs were as follows: VAS of 7.2 ± 1.9, SSV of 54 ± 22%, and ASES of 52 ± 25. Preoperatively, patients had a mean FF ROM of 146 ± 35° and ER ROM of 47 ± 13°. In addition, only 22.5% and 44.9% of patients had 5/5 strength preoperatively in FF and ER, respectively. Preoperative baselines are outlined in Table 3.
      Table 3Comparison Between Outcomes Preoperatively Versus Postoperatively After Rotator Cuff Repair in Patients With Glenohumeral Osteoarthritis
      OutcomePreoperative (n = 91)Postoperative (n = 91)P Value
      Repair failure, %NA9.9NA
      VAS7.2 ± 1.91.8 ± 2.8

      74.7% achieving MCID
      <.001
      SSV, %54 ± 2283 ± 18

      69.2% achieving MCID
      <.001
      ASES52 ± 25 (n = 33)58 ± 23

      60.6% achieving MCID (n = 33)
      .048
      ROM FF, °146 ± 35154 ± 21.012
      ROM ER, °47 ± 1347 ± 12.737
      ROM IR (level), %
       T1-T1271.483.1
       L1-L522.614.3.000
       Sacrum6.02.6
      Strength FF (MMT, %)
       ≤3/52.20.0.000
       4/565.317.8
       5/522.582.2
      Strength ER (MMT, %)
       ≤3/51.20.0.000
       4/553.914.4
       5/544.985.6
      Strength IR (MMT, %)
       ≤3/500.003
       4/526.45.7
       5/573.694.3
      NOTE. Significance set at P value < .05 (bold).
      ASES, American Shoulder and Elbow Surgeons score; ER, external rotation; FF, forward flexion; GH, glenohumeral; IR, internal rotation; L, lumbar; MMT, manual muscle test; NA, not available; ROM, range of motion; SSV, subjective shoulder value; T, thoracic; VAS, visual analog scale.

      Patient-Reported Outcomes

      Postoperative VAS was 1.8 ± 2.8, significantly decreased compared with preoperative VAS by an average of 5.4 points (P < .001). MCID for VAS was achieved in 74.7% (68/91 patients) postoperatively. Postoperative ASES was 58 ± 23, significantly increased compared with preoperative ASES by an average of 6 points (P = .048). MCID for ASES was achieved in 60.6% (20/33 patients). Finally, postoperative SSV was 83 ± 18%, a significant increase from preoperative baseline by 29% (P < .001) (Table 3). MCID for SSV was achieved in 69.2% (63/91 patients).
      Obesity (β = 1.59, P = .023) and diabetes (β = 1.46, P = .010) were found to be predictive of increased postoperative VAS pain scores (Table 4). Obesity (β = –24.48, P = .029) and tobacco use (β = –50.16, P = .007) were predictive of lower ASES scores postoperatively (Table 4). No demographic variables or injury patterns were predictive of SSVs (Table 4).
      Table 4Summary of Multivariate Linear Regression for Patient-Reported Outcomes by Demographic and Injury Patterns
      Coefficient (β)95% CI (β)P Value
      VAS (n = 91)
      Age0.020–0.058 to 0.097.615
      Obesity (BMI ≥30)1.5930.225 to 2.961.023
      Female sex0.914–0.415 to 2.244.174
      Tobacco use1.455–0.824 to 3.734.206
      Alcohol use–0.133–1.494 to 1.227.845
      Diabetes2.9670.751 to 5.183.010
      Hypercholesterolemia0.215–1.456 to 1.886.797
      Partial-thickness tear (as opposed to full-thickness tear)0.095–1.341 to 1.531.895
      Concomitant bicep tendon pathology–0.376–1.757 to 1.005.588
      Moderate-to-severe OA (as opposed to mild OA)0.165–1.340 to 1.669.827
      ASES (n = 33)
      Age–0.032–1.180 to 1.1160.954
      Obesity (BMI ≥30)–24.478–46.250 to –2.706.029
      Female sex12.175–10.107 to 34.457.268
      Tobacco use–50.155–84.757 to – 15.552.007
      Alcohol use3.026–17.048 to 23.099.756
      Diabetes–23.973–51.860 to 3.914.088
      Hypercholesterolemia–5.425–32.991 to 22.144.686
      Partial-thickness tear (as opposed to full-thickness tear)–6.943–31.220 to 17.334.557
      Concomitant bicep tendon pathology–3.232–15.914 to 22.377.728
      Moderate to severe OA (as opposed to mild OA)–17.000–38.417 to 4.417.113
      SSV (n = 91)
      Age–0.109–0.707 to 0.489.716
      Obesity (BMI ≥30)–1.705–12.147 to 8.737.745
      Female sex–4.300–14.576 to 5.977.405
      Tobacco use–4.033–21.116 to 13.051.638
      Alcohol use4.292–5.852 to 14.437.400
      Diabetes6.702–9.531 to 22.936.411
      Hypercholesterolemia–5.246–17.886 to 7.395.409
      Partial-thickness tear (as opposed to full-thickness tear)–0.803–11.303 to 9.698.879
      Concomitant bicep tendon pathology–5.848–16.525 to 4.829.277
      Moderate-to-severe OA (as opposed to mild OA)–7.397–18.945 to 4.188.206
      NOTE. Significance set at P value < .05 (bold).
      ASES, American Shoulder and Elbow Surgeons score; BMI, body mass index; OA, osteoarthritis; SSV, subjective shoulder value; VAS, visual analog scale.

      ROM Outcomes

      Average postoperative FF ROM was 154 ± 21°, whereas ER ROM was 47 ± 12°. Postoperative FF ROM was significantly improved from preoperative baseline by 8 degrees (P = .012), but postoperative ER ROM was not significantly improved (P = .737) (Table 3). Demographic variables were not predictive of decreased ROM in FF or ER (Table 5). Injury patterns were not prognostic indicators for ER ROM (Table 5). However, compared with mild OA, moderate-to-severe OA was predictive of lower ROM in FF (β = –12.4, P = .029) (Table 5).
      Table 5Summary of Multivariate Linear Regression for Range of Motion by demographic and Injury Patterns
      Coefficient (β)95% CI (β)P Value
      Forward flexion (n = 91)
      Age–0.091–0.647 to 0.464.744
      Obesity (BMI ≥30)3.125–6.767 to 13.017.531
      Female sex0.293–9.075 to 9.660.951
      Tobacco use–8.541–22.500 to 5.417.227
      Alcohol use0.896–8.773 to 10.565.854
      Diabetes–6.632–22.170 to 8.906.398
      Hypercholesterolemia3.173–9.590 to 15.936.622
      Partial-thickness tear (as opposed to full-thickness tear)0.532–9.464 to 10.529.916
      Concomitant bicep tendon pathology0.495–9.335 to 10.325.920
      Moderate-to-severe OA (as opposed to mild OA)–12.423–23.483 to –1.363.028
      External rotation (n = 91)
      Age57.336–0.461 to 0.186.401
      Obesity (BMI ≥30)0.431–5.163 to 6.025.878
      Female sex–0.251–5.556 to 5.055.925
      Tobacco use–3.449–11.412 to 4.515.391
      Alcohol use3.604–1.883 to 9.090.195
      Diabetes2.880–5.900 to 11.661.515
      Hypercholesterolemia–6.054–13.272 to 1.164.099
      Partial-thickness tear (as opposed to full-thickness tear)0.130–5.567 to 5.827.964
      Concomitant bicep tendon pathology–1.106–6.699 to 4.487.695
      Moderate-to-severe OA (as opposed to mild OA)–1.449–7.796 to 4.899.878
      NOTE. Significance set at P value < .05 (bold).
      BMI, body mass index; OA, osteoarthritis.

      Strength Outcomes

      In postoperative strength testing, 82% of patients had 5/5 FF strength and 86% had 5/5 ER strength, both significantly improved from 22.5% and 44.9%, respectively (P < .001 for both) (Table 3). No demographic variables or injury patterns were predictive of strength outcomes in ER (Table 6). However, compared with mild OA, patients with moderate-to-severe OA were less likely to have full strength in FF (odds ratio 0.226; 95% confidence interval 0.059-0.868; P = .03) (Table 6).
      Table 6Odds of Full (5/5) Postoperative Strength in Forward Flexion and External Rotation by Demographic and Injury Patterns
      Forward Flexion (n = 91)Odds of 5/5 Strength in Forward Flexion95% CIP Value
      Age0.9900.916 -1.070.806
      Obesity (BMI ≥30)2.6820.609-11.808.192
      Female sex0.7850.205-3.003.055
      Tobacco use0.3420.065-1.810.207
      Alcohol use1.4660.409-5.253.557
      Diabetes0.9390.127-6.721.939
      Hypercholesterolemia1.2150.208-7.087.829
      Partial-thickness tear (as opposed to full-thickness tear)4.2350.815-22.000.086
      Concomitant bicep tendon pathology1.3540.349-5.253.661
      Moderate-to-severe OA (as opposed to mild OA)0.2260.059-0.868.030
      External Rotation (n = 91)Odds of 5/5 Strength in External Rotation95% CIP Value
      Age1.0110.935-1.093.784
      Obesity (BMI ≥30)1.1200.265-4.731.877
      Female sex0.6780.174-2.635.574
      Tobacco use0.2170.043-1.105.066
      Alcohol use0.8420.225-3.155.799
      Diabetes1.0550.148-7.523.957
      Hypercholesterolemia0.5640.095-3.347.528
      Partial-thickness tear (as opposed to full-thickness tear)2.7330.567-13.159.210
      Concomitant bicep tendon pathology0.8420.207-3.431.810
      Moderate-to-severe OA (as opposed to mild OA)0.3250.082-1.282.109
      NOTE. Significance set at P value < .05 (bold).
      BMI, body mass index; CI, confidence interval; OA, osteoarthritis.

      Repair Failure Outcomes

      Symptomatic repair failure occurred in 9.9% (9/91 patients) of the total cohort at the minimum of 1-year follow up (Table 3). Failure occurred at similar rates in patients with partial-thickness and full-thickness tears, at 8.8% (3/34 patients) and 10.5% (6/57 patients), respectively. No demographic variables or injury patterns were prognostic indicators of repair failure (Table 7).
      Table 7Odds of Repair Failure by Demographic and Injury Patterns
      Variable (n = 91)Odds Ratio of Repair Failure95% CIP Value
      Age1.0200.921-1.130.702
      Obesity (BMI ≥30)0.8670.714-1.052.148
      Female sex5.7490.962-34.376.055
      Tobacco use2.5590.290-22.580.398
      Alcohol use2.0280.390-10.550.400
      Diabetes2.9200.388-21.961.298
      Hypercholesterolemia1.2440.233-11.884.445
      Partial-thickness tear (as opposed to full-thickness tear)0.4030.059-2.762.355
      Concomitant bicep tendon pathology0.2140.039-1.161.074
      Moderate-to-severe OA (as opposed to mild OA)0.1910.018-1.993.166
      BMI, body mass index; CI, confidence interval; OA, osteoarthritis.

      Discussion

      Overall, we found that certain risk factors in the OA population may predict greater pain scores, worse ASES scores, and diminished ROM/strength outcomes postoperatively. Obesity and diabetes were significant predictors of greater pain scores postoperatively. In addition, obesity and tobacco use were significant predictors of lower ASES scores postoperatively. Finally, moderate-to-severe OA was a significant risk factor for decreased ROM and strength in FF postoperatively compared with mild OA. No risk factors were predictive of SSV, ROM/strength in ER, and symptomatic repair failure.
      It is important to note that the suboptimal outcomes in patients with severe OA as opposed to mild OA were related to objective functional outcomes (FF strength and ROM) rather than subjective PROs. This may indicate that patients with severe OA may expect similar satisfaction and subjective results, regardless of their relative functional deficits postoperatively. Worse pain and ASES scores, however, were associated with other lifestyle factors and comorbidities including obesity, tobacco use, and diabetes. Furthermore, other injury characteristics besides OA severity, including tear thickness and concomitant bicep pathology, did not seem to affect outcomes. Regardless of risk factors, however, the results of this study indicate that RCR remains an excellent treatment option in patients with concomitant glenohumeral OA. All postoperative PROs, ROMs, and strength outcomes improved significantly from their preoperative baselines except for ER ROM.
      The risk factors for poor RCR outcomes in patients with glenohumeral OA are not well understood. Previous studies, however, have assessed prognostic factors for RCR in the general population.
      • Sahni V.
      • Narang A.M.
      Review Article: Risk factors for poor outcome following surgical treatment for rotator cuff tear.
      This study found that obesity (defined as BMI ≥30) was a predictor of greater pain scores and decreased ASES scores postoperatively in patients with glenohumeral OA. Obesity has been associated with fatty degeneration of the rotator cuff and has been proposed as an explanation for worse outcomes in this population.
      • Matson A.P.
      • Kim C.
      • Bajpai S.
      • Green C.L.
      • Hash T.W.
      • Garrigues G.E.
      The effect of obesity on fatty infiltration of the rotator cuff musculature in patients without rotator cuff tears.
      However, in this study, there was no significant difference in the supraspinatus Goutallier classifications between obese and non-obese patients. While comparative studies, including Warrender et al.
      • Warrender W.J.
      • Brown O.L.
      • Abboud J.A.
      Outcomes of arthroscopic rotator cuff repairs in obese patients.
      and Kessler et al.
      • Kessler K.E.
      • Robbins C.B.
      • Bedi A.
      • Carpenter J.E.
      • Gagnier J.J.
      • Miller B.S.
      Does increased body mass index influence outcomes after rotator cuff repair?.
      have shown worse repair outcomes in patients with obesity, retrospective review studies with multivariate analyses have failed to identify obesity as an independent risk factor for poor outcomes.
      • Namdari S.
      • Baldwin K.
      • Glaser D.
      • Green A.
      Does obesity affect early outcome of rotator cuff repair?.
      ,
      • Kuptniratsaikul V.
      • Laohathaimongkol T.
      • Umprai V.
      • Yeekian C.
      • Prasathaporn N.
      Pre-operative factors correlated with arthroscopic reparability of large-to-massive rotator cuff tears.
      We found that tobacco use was an independent predictor of decreased ASES scores postoperatively in patients with glenohumeral OA. Although the evidence in the general population remains conflicting,
      • Raman J.
      • Walton D.
      • MacDermid J.C.
      • Athwal G.S.
      Predictors of outcomes after rotator cuff repair-A meta-analysis.
      a study by Naimark et al.
      • Naimark M.
      • Robbins C.B.
      • Gagnier J.J.
      • et al.
      Impact of smoking on patient outcomes after arthroscopic rotator cuff repair.
      of 126 RCRs using regression analysis also revealed worse improvement in ASES scores among smokers. This may be due to nicotine’s potent vasoconstrictive effects which may decrease oxygen delivery to soft tissues and negatively affect healing.
      • Baumgarten K.M.
      • Gerlach D.
      • Galatz L.M.
      • et al.
      Cigarette smoking increases the risk for rotator cuff tears.
      We found diabetes to be associated with increased VAS pain scores postoperatively in patients with glenohumeral OA. This is consistent with the literature in the general population, as Sayegh et al.
      • Sayegh E.T.
      • Gooden M.J.
      • Lowenstein N.A.
      • Collins J.E.
      • Matzkin E.G.
      Patients with diabetes mellitus experience poorer outcomes after arthroscopic rotator cuff repair.
      and Berglund et al.
      • Berglund D.D.
      • Kurowicki J.
      • Giveans M.R.
      • Horn B.
      • Levy J.C.
      Comorbidity effect on speed of recovery after arthroscopic rotator cuff repair.
      both demonstrated that patients with diabetes mellitus undergoing arthroscopic RCR experienced more pain and had poorer ASES scores at 6 and 12 months. These findings have been attributed to significantly reduced collagen fiber cross-linking and fibrocartilage formation in the setting of hyperglycemia.
      • Bedi A.
      • Fox A.J.S.
      • Harris P.E.
      • et al.
      Diabetes mellitus impairs tendon-bone healing after rotator cuff repair.
      Finally, we found severity of OA to be a negative prognostic factor for postoperative strength and ROM during FF in patients with glenohumeral OA. Patients with severe glenohumeral OA, when treated surgically, are often treated with shoulder arthroplasty. As such, most of the literature regarding RCR in patients with glenohumeral OA involves cases with mild OA.
      • Kim D.H.
      • Min S.G.
      • Lee H.S.
      • et al.
      Clinical outcome of rotator cuff repair in patients with mild to moderate glenohumeral osteoarthritis.
      ,
      • Jeong H.Y.
      • Jeon Y.S.
      • Lee D.K.
      • Rhee Y.G.
      Rotator cuff tear with early osteoarthritis: How does it affect clinical outcome after large to massive rotator cuff repair?.
      However, a previous comparative study with this same patient cohort found that RCR may be a successful treatment with outcomes comparable with those without OA, and may still be a viable treatment option in patients with moderate-to-severe glenohumeral OA but with decreased strength and ROM outcomes compared with mild OA.
      • Reddy R.P.
      • Solomon D.A.
      • Hughes J.D.
      • Lesniak B.P.
      • Lin A.
      Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.

      Limitations

      This study is not without limitations. First, as a retrospective cohort study, the sample size is limited by the inclusion criteria. The limited sample size may be a reason that this study found no significant predictors of repair failure, as there were only 9 repair failures. Second, retear outcomes were measured based on symptomatic failure confirmed on MRI. As MRI was not standard for all patients, asymptomatic retears may have been missed. Third, this study included supraspinatus tears with concomitant infraspinatus/subscapularis tears, which may serve as a confounder for functional ROM and strength outcomes. Finally, this study may contain selection bias, as some patients in the initial cohort were excluded due to lack of 1-year follow up. Those lost to follow-up may have had better outcomes than those who continued to follow up at 1 year.

      Conclusions

      Tobacco use, obesity, and diabetes are associated with worse pain and PROs following arthroscopic RCR in the context of glenohumeral OA. In addition, moderate-to-severe OA is associated with worse strength and FF compared with those with mild OA.

      Supplementary Data

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