Reversing Chronic Pseudoparesis Secondary to Massive, Irreparable Rotator Cuff Tear: Superior Capsular Reconstruction vs Reverse Total Shoulder Arthroplasty

Recent studies have defined pseudoparesis as limited active forward elevation (AFE) between 45 and 90° and maintained passive range of motion in the setting of a massive rotator cuff tear (RCT). While pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable rotator cuff tear (miRCT).This was a retrospective cohort study of consecutive patients aged 40-70 with pseudoparesis secondary to miRCT that were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016-2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was utilized to compare active range of motion, visual analog pain scale (VAS), subjective shoulder value (SSV), and American Shoulder and Elbow Surgeons (ASES) score between RSA and SCR while controlling for confounding variables.Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs 54.2 ± 7.8 years, p<0.001) and had more severe arthritis (1.8 ± 0.9 vs 1.2 ± 0.5 Samilson-Prieto, p=0.019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89 ± 26 vs 73 ± 30 change in degrees, p=0.048), greater postoperative SSV (91 ± 8% vs 69 ± 25%, p<0.001), lower postoperative VAS pain scores (0.6 ± 1.2 vs 2.2 ± 2.9, p=0.020), and less postoperative IR (4.6 ± 1.6 vs 6.9 ± 1.8, p=0.004) compared to SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β = 21.5, p = 0.021) and lower VAS scores (β = -1.4, p=0.037), while SCR was predictive of greater IR ROM (β = 3.0, p=0.043).While both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less internal rotation after controlling for age and osteoarthritis. The results of this study may inform surgical decision-making for patients who are suitable candidates for either procedure.