European Journal of Cardiovascular Medicine

Total Shoulder Arthroplasty (TSA) is a widely performed surgical procedure for managing end-stage glenohumeral arthritis and other degenerative shoulder conditions. It has shown significant success in improving pain relief, restoring shoulder function, and enhancing overall quality of life (1,2). However, postoperative outcomes can vary due to multiple factors, including rotator cuff integrity, glenoid morphology, and pre-existing cartilage damage (3). Identifying these factors preoperatively is crucial for optimizing surgical planning and patient prognosis.

Arthroscopic evaluation before TSA provides direct visualization of intra-articular structures, allowing for a more comprehensive assessment of rotator cuff integrity, labral pathology, and the degree of chondral damage (4,5). Previous studies suggest that patients with intact rotator cuffs experience better functional recovery following TSA, whereas those with partial or full-thickness tears may have inferior outcomes (6). Similarly, glenoid morphology plays a critical role in implant selection and surgical technique, with severe glenoid erosion potentially leading to postoperative complications, such as instability and implant loosening (7,8). Despite these associations, the routine use of arthroscopy before TSA remains a subject of debate, as its impact on predicting surgical outcomes has not been extensively studied.

This study aims to evaluate the role of arthroscopic assessment in predicting postoperative functional and clinical outcomes of TSA. By correlating preoperative arthroscopic findings with postoperative shoulder function and pain relief, we seek to determine whether this diagnostic tool enhances outcome prediction and surgical decision-making.

Study Design and Participants

A total of 100 patients diagnosed with end-stage glenohumeral arthritis and scheduled for Total Shoulder Arthroplasty (TSA) were enrolled. Inclusion criteria included patients aged 50 years or older with primary osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis of the shoulder. Patients with prior shoulder surgery, severe rotator cuff deficiency, or significant neurological disorders affecting shoulder function were excluded.

Preoperative Arthroscopic Evaluation

All patients underwent diagnostic arthroscopy prior to TSA under general anaesthesia. The arthroscopic evaluation assessed rotator cuff integrity, glenoid morphology, labral condition, and cartilage wear. Rotator cuff status was classified as intact, partial-thickness tear, or full-thickness tear. Glenoid morphology was categorized based on the Walch classification, and cartilage damage was graded using the Outerbridge classification.

Surgical Procedure

Following arthroscopic assessment, patients underwent TSA using a standardized surgical technique. The choice of implant (anatomic or reverse TSA) was based on arthroscopic findings and preoperative imaging. A deltopectoral approach was used for all procedures, and soft tissue balancing was performed as needed. Postoperative rehabilitation followed a structured protocol, including immobilization for the initial two weeks, followed by gradual passive and active-assisted range of motion exercises.

Outcome Measures

Clinical and functional outcomes were assessed preoperatively and at 6 and 12 months postoperatively using the following tools:

• Constant-Murley Score (CMS): Evaluates pain, activities of daily living, range of motion, and strength.
• American Shoulder and Elbow Surgeons (ASES) Score: Measures pain and functional limitations.
• Visual Analog Scale (VAS): Assesses pain intensity on a scale from 0 (no pain) to 10 (severe pain).

Statistical Analysis

Data were analyzed using SPSS software (version 26). Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Comparisons between groups were performed using the independent t-test for continuous variables and the chi-square test for categorical data. Pearson’s correlation coefficient was used to determine the relationship between arthroscopic findings and postoperative outcomes. A p-value of <0.05 was considered statistically significant.

Demographic and Clinical Characteristics

A total of 100 patients (mean age: 62 ± 8 years; 55 males and 45 females) were included in the study. The mean duration of symptoms before surgery was 5.2 ± 1.4 years. Rotator cuff integrity was classified as intact in 58 patients, partial-thickness tear in 27 patients, and full-thickness tear in 15 patients. Glenoid morphology assessment showed that 45 patients had type A, 35 had type B, and 20 had type C glenoid morphology (Table 1).

Table 1: Baseline Characteristics of Patients

Functional Outcomes

Postoperative functional scores significantly improved in all patients. At 12 months, the mean Constant-Murley Score (CMS) increased from 42.3 ± 7.1 preoperatively to 75.6 ± 6.4 (p < 0.001), and the mean ASES score improved from 38.5 ± 6.8 to 82.1 ± 5.9 (p < 0.001). Patients with intact rotator cuffs demonstrated superior postoperative CMS (78.2 ± 5.5) compared to those with partial-thickness (69.3 ± 6.2) and full-thickness tears (61.4 ± 5.8; p < 0.05) (Table 2).

Table 2: Comparison of Preoperative and Postoperative Functional Outcomes

Pain Reduction

VAS scores showed a significant decline postoperatively. Preoperatively, the mean VAS score was 7.5 ± 1.2, which improved to 3.8 ± 1.1 at 6 months and further reduced to 2.3 ± 1.0 at 12 months (p < 0.001) (Table 3). Patients with intact rotator cuffs reported lower pain levels at 12 months compared to those with partial or full-thickness tears.

Table 3: Changes in Pain Scores (VAS) Over Time

Correlation Between Arthroscopic Findings and Postoperative Outcomes

Statistical analysis revealed a strong correlation between arthroscopic findings and postoperative outcomes. Patients with less severe cartilage damage and intact rotator cuffs achieved higher functional scores and experienced greater pain relief. Glenoid morphology also influenced outcomes, with type A morphology yielding better results than type B or C.

These findings suggest that arthroscopic evaluation provides valuable predictive insights for postoperative recovery following TSA.

This study highlights the significant role of preoperative arthroscopic evaluation in predicting postoperative outcomes of Total Shoulder Arthroplasty (TSA). Our findings indicate that arthroscopic assessment of rotator cuff integrity, glenoid morphology, and cartilage condition correlates strongly with postoperative functional improvements and pain reduction. These insights are crucial for optimizing surgical planning and improving patient outcomes.

Impact of Rotator Cuff Integrity on Postoperative Outcomes

Rotator cuff status is a critical determinant of TSA success. Patients with intact rotator cuffs demonstrated superior functional outcomes, as evidenced by higher postoperative Constant-Murley (CMS) and American Shoulder and Elbow Surgeons (ASES) scores. In contrast, those with partial or full-thickness tears had comparatively lower improvements in function and higher residual pain levels. Similar findings have been reported in previous studies, where compromised rotator cuffs were associated with inferior postoperative recovery and increased risk of complications such as implant loosening and shoulder dysfunction (1,2). The importance of preoperative rotator cuff assessment has been emphasized in literature, as early detection can guide the choice between anatomic and reverse TSA, ensuring optimal outcomes (3,4).

Influence of Glenoid Morphology on Functional Recovery

Glenoid morphology plays a vital role in postoperative shoulder function and implant longevity. Our study found that patients with Type A glenoids had significantly better outcomes compared to those with Type B or Type C glenoids. This is in accordance with previous research indicating that severe glenoid erosion, particularly in Type B2 and C cases, is linked to increased risk of glenoid component loosening and postoperative instability (5,6). Proper preoperative classification of glenoid morphology can assist in implant selection and surgical technique modifications, such as augmented glenoid components or bone grafting, to optimize joint stability (7,8).

Role of Preoperative Cartilage Assessment in Outcome Prediction

The extent of cartilage degeneration observed during arthroscopy correlated strongly with postoperative pain relief and functional recovery. Patients with lower Outerbridge grades of cartilage wear showed superior improvement in VAS pain scores and functional assessments. Studies have demonstrated that advanced chondral wear is associated with higher rates of implant-related complications and persistent postoperative discomfort (9,10). Arthroscopic evaluation allows for early identification of patients who may require additional procedures, such as microfracture or cartilage resurfacing techniques, to enhance long-term outcomes (11).

Comparison with Existing Literature

Our findings align with previous studies that emphasize the predictive value of arthroscopic evaluation before TSA. Boileau et al. (12) reported that preoperative arthroscopy provided crucial diagnostic insights that influenced surgical decision-making, leading to better functional outcomes. Similarly, Millett et al. (13) highlighted that arthroscopy could identify subtle intra-articular pathologies that may not be evident on imaging, thereby aiding in patient selection for TSA. Furthermore, Denard and Burkhart (14) suggested that preoperative arthroscopy might be beneficial in detecting synovitis and early degenerative changes that could affect implant survival.

While previous studies have focused primarily on individual aspects such as rotator cuff integrity or glenoid wear, our study integrates multiple arthroscopic findings to establish a comprehensive predictive model for TSA outcomes. This holistic approach underscores the potential benefits of routine preoperative arthroscopic assessment in TSA candidates.

Clinical Implications

The results of this study suggest that arthroscopic evaluation should be considered as a standard preoperative assessment in patients undergoing TSA. By identifying risk factors for suboptimal outcomes, surgeons can tailor surgical approaches, modify rehabilitation protocols, and provide more accurate prognostic information to patients. Additionally, patients with severe intra-articular pathology detected arthroscopically may be better candidates for reverse TSA rather than anatomic TSA, reducing the likelihood of revision surgery (15).

Limitations and Future Directions

Despite its strengths, this study has certain limitations. The sample size, although adequate, may not be representative of the broader population undergoing TSA. Additionally, longer follow-up periods are required to assess the durability of the observed functional improvements. Future studies with larger cohorts and multicentre data collection could further validate our findings and refine predictive models for TSA outcomes.

Preoperative arthroscopic evaluation provides valuable prognostic information for patients undergoing TSA. Rotator cuff integrity, glenoid morphology, and cartilage condition significantly influence postoperative functional recovery and pain relief. Integrating arthroscopy into the preoperative assessment protocol can enhance surgical decision-making, optimize implant selection, and improve long-term patient outcomes. Further research is warranted to establish standardized guidelines for incorporating arthroscopic findings into TSA planning.

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