Impact of osteoporosis on post-operative outcomes following rotator cuff repair

Osteoporosis, a systemic skeletal disorder marked by reduced bone mineral density and increased fracture risk, is especially prevalent in postmenopausal women and older adults, populations that commonly undergo rotator cuff repair (RCR) surgery. However, large-scale clinical evidence evaluating the association between osteoporosis and post-operative outcomes following RCR remains limited. This study evaluated post-operative complication rates and health care utilization following RCR in patients with and without osteoporosis.

Using the PearlDiver Mariner170 database, patients with and without a diagnosis of osteoporosis who also underwent RCR surgery were propensity matched 1:1. Primary study outcomes included 2-year RCR revision surgery, conversion to reverse total shoulder arthroplasty (rTSA), and pathological fractures of the humerus. Secondary outcomes included 90-day wound complications, shoulder stiffness, thromboembolic events, infections, and health care utilization. Analyses were conducted for the full RCR cohort as well as separately for open and arthroscopic RCR subgroups. Within the cohort of osteoporotic patients, outcomes were compared between patients who underwent open vs. arthroscopic RCR. Welch t-test and chi-square tests were used for continuous and categorical variables, respectively, with a Bonferroni-corrected significance ( $\alpha$ = 0.002).

After matching, 65,118 patients of similar age (66.4 years), gender distribution (87.1% female), and comorbidity burdens (Elixhauser Comorbidity Index: 5.3) were included in the osteoporosis and no-osteoporosis cohorts. At 2 years following RCR, osteoporotic patients had significantly higher rates of rTSA and pathological humeral fractures, but no difference in revision RCR. Within 90 days, osteoporotic patients experienced a higher incidence of general surgical complications, anemia, shoulder stiffness, and medical visits. Subgroup analyses between open and arthroscopic RCR demonstrated similar trends between the 2 procedure types. Among osteoporotic patients, those who underwent open RCR had higher rates of rTSA, revision RCR, and pathological humeral fractures than their arthroscopic RCR counterparts.

In the setting of RCR, patients with osteoporosis demonstrated higher rates of conversion to rTSA and pathological humeral fractures within 2 years of tendon repair compared to patients without a diagnosis of osteoporosis, regardless of surgical approach. In addition, patients with osteoporosis may experience a higher incidence of medical complications within the 90-day global period than nonosteoporotic patient. In the subgroup of patients with osteoporosis, open RCR was associated with higher 2-year rates of rTSA, revision RCR, and pathological fractures when compared to arthroscopic RCR. These findings suggest that bone health evaluation prior to RCR may be prudent to facilitate pre-operative optimization, surgical planning, and post-operative protocols to reduce complications and improve outcomes.