Summary

Patients with coronary artery disease and peripheral arterial disease undergoing rotator cuff repair experience significantly higher rates of postoperative complications and re-tears, indicating that arterial disease may impair tendon healing and affect surgical outcomes.

Abstract

Introduction

Impaired rotator cuff tendon vascular supply is suggested to play a critical role in tendon degeneration and in tendon healing following rotator cuff repair. Studies further demonstrate that in addition to vessel blockage, the state of hyperlipidemia drives a pro-inflammatory immune response altering tendon homeostasis and the extracellular matrix. Further, the subsequent oxidative stress plays a direct role in tendon degeneration. There is a paucity of literature demonstrating the impact on outcomes of arterial disease in patients undergoing rotator cuff repair while stratifying patients by disease severity. The purpose of this matched cohort analysis is to characterize the effect of coronary artery disease (CAD) and peripheral arterial disease (PAD) in rotator cuff repairs stratifying patients by severity of vessel disease.

Materials And Methods

A large commercial insurance claims database was queried for all patients who underwent primary rotator cuff repair between 2010 and 2020 with at least 3 months of follow-up. Patients were stratified by pre-operative diagnosis of coronary artery disease or peripheral arterial disease into disease and control groups. Groups were matched in an approximately 1:1:1 ratio of disease and control by age, gender, and tear type. The patients were stratified by disease severity based on procedure codes for stents, vascular bypass including coronary artery bypass graft (CABG) and peripheral bypass procedures. The primary outcomes were a diagnosis of a repeat tear and consequent revision rotator cuff repair. Secondary outcomes included post-operative complications.

Results

80,152 patients who underwent primary rotator cuff repair (63% right-sided) were included in the initial patient population. Of these, 22,735 had a diagnosis of coronary artery disease alone and 8,610 had a diagnosis of peripheral arterial disease alone. Following matching, the CAD, PAD, and control cohorts each contained 15,967 patients. Each cohort contained a similar proportion in gender, age, and tear type (complete/partial). Baseline demographics between the disease and control groups differed significantly with respect to Charlson Comorbidity Index (CCI), asthma, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, diabetes, hypertension, obesity, osteoarthritis, pulmonary heart disease, rheumatoid arthritis, and tobacco usage. Complications after the primary repair were significantly higher in the CAD and PAD cohorts compared to the control cohort including ED visits, skin and soft tissue infection, acute kidney injury, cardiac arrythmia, deep vein thrombosis, wound disruption, hematoma, nerve injury, pneumonia, pulmonary embolism, transfusions, urinary tract infection, sepsis, joint infection, readmission, ICU admission, adhesive capsulitis, and manipulation under anesthesia (Table 1). Multivariate modeling controlling for Charlson Comorbidity Index, age, and gender demonstrated that isolated CAD (OR 4.04, 95% CI 3.79-4.31, p < 0.001) and PAD (OR 2.83, 95% CI 2.66-3.02, p < 0.001) diagnosis were significant predictors of all-cause complications within 90 days. Rates of re-tears were significantly higher in the CAD (OR 1.17, 95% CI 1.01-1.36, p = 0.003) and PAD (OR 1.28, 95% CI 1.27 – 1.29, p = 0.003) cohorts. Further, rates of rotator cuff revision trended higher in the CAD cohort (OR 1.19, 95% CI 0.93-1.52, p = 0.08) and PAD cohort (OR-1.30, 95% CI 1.29-1.33, p = 0.08) than the control group (Table 2). Multivariate modeling for re-tears and revisions demonstrated no significant difference in outcomes when comparing CAD patients with CABG, bypass, or no interventions, and no significant difference in outcomes when comparing PAD patients undergoing peripheral bypass, stents, or no interventions.

Discussion

Compared to the control cohort, patients with diagnosis of coronary artery disease and peripheral arterial disease had approximately 25% higher rates of complications following primary rotator cuff repair. Further, patients with arterial disease had significantly higher rates of re-tear suggesting a role of arterial patency in tendon healing following surgery. There was no statistically significant difference in revision rates (p = 0.08). While limited by the significant differences in comorbidities in the cohorts, these data concur with studies demonstrating atherosclerosis affecting rotator cuff tendons and can assist in informing patients with arterial disease of complications and outcomes following rotator cuff repair.