Factors influencing functional internal rotation after reverse total shoulder arthroplasty

Functional internal rotation (fIR) of the shoulder is frequently limited after reverse shoulder arthroplasty (RTSA). The objective of this study was to study a cohort of satisfied patients after RTSA who had comparable active mobility except for fIR and to identify factors associated with selective loss of fIR.

A retrospective cohort study was conducted to compare 2 patient groups with either poor (≤ 2 points in the Constant-Murley score [CS]) or excellent (≥8 points in CS) fIR after RTSA at a minimum follow-up of 2 years. Influencing factors (demographic, surgical or implant related, radiographic parameters) and clinical outcome were analyzed.

Fifty-two patients with a mean age of 72.8 (±9.3) and a mean follow-up of 41 months were included in the IR≤2 group and 63 patients with a mean age of 72.1 (±8.0) and a mean follow-up of 59 months in the IR≥8 group. All patients had undergone RTSA with the same implant type and only 2 different glenosphere sizes (36 and 40) for comparable indications. A multivariate analysis identified the following significant risk factors for poor postoperative fIR: poor preoperative fIR (pts in CS: 3 [range: 2-6] vs. 6 [range: 4-8], P<.0001), smoking (17.3% vs. 6.5%, P = .004), male gender (59.6% vs. 31.7%, P = .002), less preoperative to postoperative distalization of the greater tuberosity (Δ 19.4 mm vs. 22.2 mm, P = .026), a thin humeral insert (≤3 mm: 23.1% vs. 54.8%, P = .039), and a high American Society of Anesthesiologists score (≤ III: 30.8% vs. 14.3%, P = .043). Subscapularis repair status and glenosphere size had no influence on fIR. Clinical outcome scores improved in both groups from preoperatively to last follow-up. The IR≥8 group had overall significantly better outcome scores compared to the IR≤2 group (Δ 9.3% SSV and Δ 9.5% relative CS, P < .0001). There was no difference in CS between the cohorts when the score for fIR was discarded.

Independent risk factors for poor postoperative fIR after RTSA are poor preoperative fIR, smoking, male gender, less preoperative to postoperative distalization of the greater tuberosity, a thin humeral insert height, and a high American Society of Anesthesiologists score. Except for male gender, these factors are modifiable. These findings may be a valuable addition to patient counselling as well as preoperative planning and preoperative and intraoperative decision-making. The relevance of fIR for overall satisfaction is substantiated by this study.