The Influence Of Rotator Cuff Muscles And Lateralization On Internal And External Rotation In Reverse Shoulder Arthroplasty

The Influence Of Rotator Cuff Muscles And Lateralization On Internal And External Rotation In Reverse Shoulder Arthroplasty | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Influence Of Rotator Cuff Muscles And Lateralization On Internal And External Rotation In Reverse Shoulder Arthroplasty Orhun Eray Bozkurt, Ugur Bezirgan, Mehmet Mesut Celebi, Ebru Dumlupinar, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6369611/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The subscapularis and its antagonist muscles, the infraspinatus-teres minor, affect functional rotational movements in daily life. A deficiency in either of these muscles leads to a strength imbalance. In patients undergoing reverse shoulder arthroplasty (RSA), the repair of the subscapularis muscle is a debated topic. This study aimed to determine the relationship between the isokinetic and endurance values of internal and external rotation in patients post-RSA, and the presence of this muscle pair and lateralization. Methods: Thirty-one patients who underwent RSA between 2020-2023 were retrospectively included in the study. Isokinetic and endurance values were measured using a dynamometer device. Lateralization was calculated from postoperative X-ray images by determining the global offset . Patients’ Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), and Constant scores were measured, and range of motion (ROM) was evaluated. Based on the presence of the subscapularis and infraspinatus-teres minor muscles, patients were divided into four groups (Group A, B, C, D). Results: Isokinetic and endurance values for both internal and external rotation were significantly higher in Group A. There was a significant and strongly negative correlation between the presence of these muscles for isokinetic and endurance values of internal and external rotation from Group A to Group D. A significant positive correlation was found between component lateralization and isokinetic and endurance values of external rotation. A significant negative correlation was identified between lateralization and internal rotation ROM difference. Conclusions: The presence of the force couple in the post-RSA period positively impacts the isokinetic and endurance values of shoulder rotational movements. Reverse shoulder arthroplasty isokinetic endurance subscapularis teres minör Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Reverse shoulder arthroplasty (RSA) has gained popularity in recent years and its use has increased for the treatment of osteoarthritis resulting from rotator cuff deficiency. It is an effective treatment method for relieving preoperative pain and improving functional capacity in patients [ 1 ]. RSA also allows for the restoration of the rotator cuff muscles and supports shoulder balance [ 2 , 3 ]. Additionally, one of the mechanisms of RSA is to increase shoulder abduction by extending the deltoid moment arm and medializing the center of rotation [ 4 , 5 ]. Although there is data in the literature regarding shoulder abduction in RSA, there is a lack of clear information on internal and external rotation [ 6 ]. The repair of the subscapularis muscle after RSA continues to be a debated topic in the literature. Some publications suggest that the repair of the subscapularis in RSA increases anterior stability and contributes to functional internal rotation [ 7 , 8 ], while others state that repairing the subscapularis muscle does not have a positive contribution in the postoperative period [ 9 , 10 ]. Therefore, the gains in rotational functional movements in daily life in these patients during the postoperative period remain controversial [ 6 ]. The anterior rotator cuff muscles (subscapularis) and the posterior rotator cuff muscles (infraspinatus and teres minor) influence internal and external rotation [ 11 ]. The presence and functionality of the subscapularis, teres minor, and infraspinatus muscles, which contribute to internal and external rotation movements in the rotator cuff muscles, affect the daily rotational movements of patients. Additionally, the balanced moment between the subscapularis and infraspinatus-teres minor muscles is referred to as the transverse force couple. Deficiency in these muscles leads to an imbalance in the force couple and disrupts stability [ 12 ] (Fig. 1 ). The aim of this study is to evaluate how much the presence of anterior and posterior rotator cuff muscles affects internal and external rotational functional movements by examining their isokinetic and endurance values. Although isokinetic and endurance evaluations have been conducted in patients undergoing RSA, there is no study showing the relationship between these evaluations and the presence of each of the rotator cuff muscles. Materials and Methods The study protocol was approved by the University Medical Faculty Human Studies Institutional Ethics Review Board (ID: İ03-257-24 ). Informed consent was obtained from all individual participants included in the study. Thirty-one patients who underwent surgery for rotator cuff arthropathy in our clinic between 2020–2023 were retrospectively included in the study (Fig. 2 ). Patients who underwent surgery for rotator cuff tear arthropathy, who had at least a year of follow-up, and who received inlay reverse shoulder arthroplasty were included in the study. Patients who underwent revision reverse shoulder arthroplasty, those who received reverse shoulder prostheses due to tumors or fractures, those who underwent onlay reverse shoulder arthroplasty, patients with follow-up of less than a year, and those with inflammatory arthropathy were excluded from the study. All patients were evaluated by the same doctor (M.Ç) using the Biodex System 4 Isokinetic Dynamometer (Biodex Medical Systems, Shirley NY, 11967, USA) after a year postoperatively. Patients, while seated with the elbow at 90° flexion, had their shoulder internal and external rotation isokinetic strength and endurance measured. The average peak torque (nm) at a speed of 60°/sec over five repetitions was determined to measure muscle strength. The total work (nm) at a speed of 180°/sec over ten repetitions was determined to measure muscle endurance (Fig. 3 ). The degree of lateralization (global offset) was measured from postoperative shoulder X-rays (Fig. 4 ) [ 13 ]. Additionally, the range of motion (ROM) for internal rotation was measured by the level reached by the thumb on the back [ 14 ], while the ROM for external rotation was measured using a universal standard goniometer. All patients were also assessed preoperatively and postoperatively with the Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), and Constant score. We used the deltopectoral approach during surgery. The supraspinatus muscle was routinely excised. Glenoid version was set to a standard 20° retroversion. During the intraoperative period, we repaired the subscapularis muscle with non-absorbable sutures whenever possible. During surgery, we assessed the tension and passive ROM of the subscapularis muscle after intraoperative repair. In cases where it was tense, we did not repair the subscapularis to avoid negatively affecting the function of the external rotator muscles or not to reduce the abductor power of the deltoid by an antagonistic effect. The integrity of the teres minor and infraspinatus muscles was evaluated preoperatively using magnetic resonance imaging (MRI), while intraoperative repair information of the subscapularis was obtained from surgical reports. Patients were divided into four groups based on the presence of these muscles: Group A included patients with a repaired subscapularis and intact teres minor/infraspinatus, Group B included patients with a repaired subscapularis and non-intact teres minor/infraspinatus, Group C included patients with a non-repaired subscapularis and intact teres minor/infraspinatus, and Group D included patients with a non-repaired subscapularis and non-intact teres minor/infraspinatus. Descriptive statistics were presented as mean ± standard deviation for the variables distributed normally and as median (min, max, IQR) for the variables distributed not normally, whereas they were presented as number and percentage (%) for nominal variables. The significance of the difference between the groups in terms of the median values was analyzed by Kruskal Wallis Test. The relationship between variables was evaluated by Spearman’s Rho Correlation Test. For the levels of the correlation coefficients, 0-0.19 no correlation, 0.40–0.59 moderate correlation, 0.60–0.79 strong correlation, 0.80-1 very strong correlation were used asthe basis for interpretation. A p value of less than 0.05 was considered statistically significant and the analyses were conducted using the Statistical Package for Social Sciences (SPSS, Version 15.0, Chicago, IL). In terms of isokinetic (ER), the total minimum number of participants required for the study to detect an effect size of 0.68 (Cohen's f) with a significance level of 0.05 and a power of 0.80 among the groups (A, B, C, D) in a 2:1:1:1 ratio is 28. The sample size calculation was performed using G*Power (version 3.1.9.4) with the 'Many groups: ANOVA: One-way' option. The imbalance in sample size is due to the unequal distribution of the groups, resulting from the fact that tears in the teres minor muscle are a rare type [ 15 ]. Results The 31 patients included in the study had an average age of 73.77 ± 8.42 years, and 26 of them (83.9%) were female. The demographic and clinical characteristics of the patients are shown in Table 1 . Radiological and functional parameters are shown in Tables 2 and 3 . There were no significant differences in internal and external rotation ROM differences between the preoperative and postoperative periods among the groups (p = 0.118, p = 0.175, respectively) (Table 4 ). Similarly, differences in VAS, Constant, and ASES scores were not significant (p = 0.115, p = 0.087, p = 0.262, respectively) (Table 4 ). Table 1 Demographic and Clinical Characteristics Age, mean ± SD 73.77 ± 8.42 Sex, n (%) Female 26 (83.9) Male 5 (16.1) Dominant Side, n(%) Right 28 (90.3) Left 3 (9.7) Operated Side, n(%) Right 25 (80.6) Left 6 (19.4) Subscapularis, n(%) Repair 18 (58.1) Non-repair 13 (41.9) Teres Minör/infraspinatus, n(%) Present 19 (61.3) Absent 12 (38.7) Groups, n(%) A* 12 (38.7) B* 6 (19.4) C* 7 (22.6) D* 6 (19.4) SD: Standart Deviation, IQR: Interquartile Range * A: Subscapularis repaired + teres minor/infraspinatus intact B: Subscapularis repaired + teres minor/infraspinatus not intact C: Subscapularis not repaired + teres minor/infraspinatus intact D: Subscapularis not repaired + teres minor/infraspinatus not intact Table 2 Radiological parameters and clinical range of motion of all patients included in the study Preop IR ROM, median (min, max, IQR) 3 (1, 5, 1) Postop IR ROM, median (min, max, IQR) 4 (3, 5, 2) Preop ER ROM, median (min, max, IQR) 20 (5, 50, 15) Postop ER ROM, median (min, max, IQR) 45 (20, 75, 15) GO, median (min, max, IQR) 3.35 (2.66, 5.7, 1.12) SD: Standart Deviation, IQR: Interquartile Range,min: minimum, max:maximum, ROM: Range of Motion IR:Internal Rotation, ER: External Rotation, GO: Global Offset Table 3 The functional scores, isokinetic strength, and endurance values of all patients included in the study Preop VAS, median (min, max, IQR) 9 (8, 10, 1) Postop VAS, median (min, max, IQR) 3 (1, 6, 3) Preop Constant, median (min, max, IQR) 33 (10, 38, 16) Postop Constant, median (min, max, IQR) 55 (40, 69, 17) Preop ASES, median (min, max, IQR) 13 (3, 37, 23) Postop ASES, median (min, max, IQR) 48 (37, 65, 22) ER isokinetic, median (min, max, IQR) 16.1 (7.9, 27.2, 9.1) IR isokinetic, median (min, max, IQR) 14.8 (6.3, 41.2, 19.3) ER endurance, median (min, max, IQR) 10.2 (5.5, 19.3, 3.1) IR endurance, median (min, max, IQR) 13.2 (5.5, 31.8, 8) IQR: Interquartile Range,min: minimum, max:maximum, VAS: Visual Analogue Scale, ASES: American Shoulder and Elbow Surgeons Score, IR:Internal Rotation, ER: External Rotation Table 4 The differences in postoperative/preoperative internal and external rotation ROM and functional score differences between groups Groups A (n = 12) B (n = 6) C (n = 7) D (n = 6) p value Difference IR , median (min, max, IQR) 1 (0, 2, 1) 1 (0, 2, 2) 1 (1, 2, 0) 2 (1, 2, 1) 0.118 a Difference ER , median (min, max, IQR) 30 (-15, 40, 10) 27.5 (25, 45, 12.5) 35 (25, 62, 10) 20 (-10, 30, 21.25) 0.175 a Difference VAS , median (min, max, IQR) 5.5 (4, 8, 2) 4 (2, 8, 3) 6 (3, 9, 3) 5 (3, 7, 4) 0.115 a Difference Constant , median (min, max, IQR) 22 (8, 50, 31) 40 (20, 45, 14.5) 20 (5, 30, 25) 15 (8, 43, 29.75) 0.087 a Difference ASES , median (min, max, IQR) 30.5 (9, 53, 22) 35 (18, 50, 20.75) 30 (8, 40, 22) 28.5 (15, 58, 29.5) 0.262 a Group A: Repaired subscapularis and intact teres minor/infraspinatus, Group B: Repaired subscapularis and non-intact teres minor/infraspinatus, Group C: Non-repaired subscapularis and intact teres minor/infraspinatus, Group D: Non-repaired subscapularis and non-intact teres minor/infraspinatus IQR: Interquartile Range, a Kruskal Wallis Test, min: minimum, max:maximum, VAS: Visual Analogue Scale, ASES: American Shoulder and Elbow Surgeons Score, IR:Internal Rotation, ER: External Rotation Isokinetic and endurance values for both internal and external rotation showed significant differences among the groups (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). Both isokinetic and endurance values were higher in Group A, regardless of internal or external rotation (Table 5 ). Table 5 Comparison of isokinetic and endurance values between groups Groups A (n = 12) B (n = 6) C (n = 7) D (n = 6) p value Isokinetic (ER), median (min, max, IQR) 20.95 y (16.1, 27.2, 7.55) 11.8 x (10.9, 12.6, 1.1) 17 xy (9.6, 19.8, 7.4) 8.5 x (7.9, 9.2, 1.07) < 0.001 a Isokinetic (IR), median (min, max, IQR) 28.05 y (12, 41.2, 12.13) 15.3 xy (14.8, 15.8, 0.85) 6.9 x (6.3, 26.3, 1.6) 8.7 x (7.2, 11, 3.12) < 0.001 a Endurance (ER), median (min, max, IQR) 11.85 y (9, 19.3, 5.8) 10.1 xy (9.6, 11.1, 1.2) 8.4 x (7.7, 10.3, 1) 7.65 x (5.5, 11.6, 5.42) 0.001 a Endurance (IR), median (min, max, IQR) 17.55 y (11.7, 31.8, 7.9) 14.7 xy (14.6, 15.3, 0.25) 7.6 x (5.5, 15.7, 2.4) 7.55 x (5.5, 10.1, 4.38) < 0.001 a Group A: Repaired subscapularis and intact teres minor/infraspinatus, Group B: Repaired subscapularis and non-intact teres minor/infraspinatus, Group C: Non-repaired subscapularis and intact teres minor/infraspinatus, Group D: Non-repaired subscapularis and non-intact teres minor/infraspinatus IQR: Interquartile Range, a Kruskal Wallis Test, min: minimum, max:maximum, IR:Internal Rotation, ER: External Rotation * The difference between medians with different character is statistically significant. When examining the correlation between muscle presence and isokinetic and endurance values of internal and external rotation, a statistically significant and strongly negative correlation was found from Group A to Group D. A significant positive correlation was found between component lateralization and external rotation isokinetic and endurance values (Table 6 ). A significant negative correlation was found between lateralization and internal rotation ROM difference (Table 7 ). Table 6 The correlation of groups and lateralization with isokinetic, endurance values of internal and external rotation Isokinetic (ER) Isokinetic (IR) Endurance (ER) Endurance (IR) Groups r -0.814 -0.779 -0.687 -0.757 p value < 0.001 < 0.001 < 0.001 < 0.001 GO r 0.414 0.145 0.37 0.344 p value 0.021 0.438 0.04 0.058 r: Spearman’s Rho Correlation Coefficient, IR:Internal Rotation, ER: External Rotation, GO: Global Offset Table 7 The correlation of groups and lateralization with the difference in internal and external rotation ROM Difference IR Difference ER Groups r 0.272 -0.206 p value 0.257 0.267 GO r -0.387 -0.226 p value 0.032 0.221 r: Spearman’s Rho Correlation Coefficient, IR:Internal Rotation, ER: External Rotation, GO: Global Offset Discussion The condition of the rotator cuff tendons, preoperative ROM, and patient-related factors can affect the functional outcome of RSA. In this study, we primarily focused on the impact of component lateralization and the integrity of rotator cuff tendons on the internal and external rotation outcomes. The biomechanical and functional characteristics of reverse shoulder arthroplasty have been among the most researched aspects in recent years [ 16 – 18 ]. These studies have particularly emphasized the function of the deltoid muscle and the abduction movement of the shoulder [ 18 – 20 ]. Additionally, there is a debate regarding the function of the subscapularis muscle and whether it should be repaired during surgery. Some studies suggest that the repair of the subscapularis muscle has a positive functional effect [ 21 – 23 ], while others have shown that it has no effect [ 24 , 25 ]. The impact of repairing the subscapularis muscle on internal and external rotation has been a topic of debate in the literature. However, there is no consensus on the effect of the subscapularis in the presence of the teres minor and infraspinatus muscles on shoulder internal and external rotation in reverse shoulder arthroplasty. In a cadaver study, significant changes were observed in the moment arms of both the teres minor and subscapularis during glenohumeral abduction. The reduced rotational moment arms due to the decreased origo-insertion distance of the muscles may be a possible explanation for the clinically observed deficiencies in external and internal rotation [ 26 ]. In a study by Erşen et al., the endurance and isokinetic values in rotational movements were found to be significantly lower in patients undergoing reverse shoulder arthroplasty compared to the contralateral shoulder, supporting this cadaver study [ 6 ]. In their study, the subscapularis muscle was repaired in all cases, but the teres minor and infraspinatus muscles were not evaluated. In this study, the contralateral shoulder was not evaluated, assuming a high risk of rotator cuff disease in it as well. Patients were examined by categorizing each muscle of the cuff separately before and after surgery. All isokinetic and endurance values for internal and external rotation were higher in Group A. This suggests that better rotational functional results can be obtained in shoulders closer to primary anatomy. Some studies suggest that the repair of the subscapularis muscle may negatively affect external rotation function [ 24 , 27 ], in this study, we found that, in addition to the presence of the teres minor muscle, repairing the subscapularis muscle (i.e., Group A) had a positive effect on external rotation isokinetic strength and endurance. In our study, the differences in ROM and functional scores between preoperative and postoperative periods were not significant in any group. This suggests that the prosthesis design in reverse shoulder arthroplasty provides sufficient improvement for daily activities regardless of the presence of the rotator cuff muscles. Additionally, it is known that the anterior and posterior fibers of the deltoid muscle, with improved function, make a significant contribution to the shoulder's internal and external rotation functions [ 28 ]. In a study involving 15 patients who underwent reverse shoulder arthroplasty and a control group of 15 healthy subjects, the operated shoulder was compared with both the contralateral shoulder and the shoulders of healthy subjects. It was found that the ROM for flexion, extension, and abduction, as well as the isokinetic values for flexion, extension, abduction, and adduction, were all lower in the operated shoulder [ 1 ]. However, the shortcoming of this study is the lack of evaluation of internal and external rotation. It is known that rotational movements are important for daily activities and tasks [ 29 ]. In this study, although postoperative ROM values improved in all groups, no significant difference was observed between the groups. Contrary to the literature, a negative correlation was found between internal rotation and prosthesis lateralization, while no correlation was found between external rotation and lateralization. This situation can be explained by the relative tension of the repaired subscapularis as the prosthesis becomes more lateralized, significantly reducing its function, or by its rerupture in the postoperative period. Additionally, it can be said that the subscapularis, which cannot be sutured due to lateralization, also reduces internal rotation ROM. In a study by De Boer et al., it was found that only ten (40%) of 25 patients who underwent reverse shoulder arthroplasty with repaired subscapularis had an intact subscapularis on control ultrasound at an average follow-up of 30 months [ 30 ]. This result shows that a portion of the repaired subscapularis muscles did not heal or reruptured. In our clinical experience, we do not repair subscapularis muscles that can be sutured intraoperatively but are tense due to the risk of rerupture in the postoperative period and because it may reduce external rotation and abduction. In this case, we try to achieve better internal and external rotation by using more lateralized components. Additionally, it has been shown that the anterior fibers of the deltoid muscle also contribute to internal rotation [ 31 ]. Studies have shown that lateralization does not affect the ability to suture, but distalization does [ 32 ]. If there is no muscle that can be sutured during surgery, we can compensate this with component lateralization [ 33 ]. Although postoperative isokinetic and endurance values for internal and external rotation were significantly different between the groups, the differences in functional scores compared to the preoperative period were not significant between the groups. However, this study showed us that isokinetic and endurance parameters maybe still important in RSA. This is because daily activities include movements that require repetitive or maximum power usage. A study with a larger sample size could provide more valuable information. The limitations of our study include the small sample size and the retrospective nature of the study. Studying the preoperative isokinetic and endurance values of patients would have made this study better for comparison purposes. Additionally, it is evident that the gender of the patients and the dominance of the operated side also affect the results. Additionally, the postoperative integrity of the subscapularis muscle in patients who underwent repair was not evaluated. Postoperative follow-up with MRI or ultrasound could have been useful for assessing rerupture. The strength of this study is that it sheds light on the future by examining the relationship between reverse shoulder arthroplasty, internal and external rotation ROM, isokinetic and endurance values, rotator cuff muscles, and component lateralization. Conclusions The ability to repair the subscapularis in the presence of the teres minor and infraspinatus has the most positive effect on the rotational movements of the shoulder. Thus, this force couple in the rotator cuff is effective even in anatomically unconventional reverse shoulder prosthesis. Additionally, component lateralization has a positive effect on the shoulder's external rotation endurance and isokinetic values. Declarations Clinical trial number : not applicable Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Ankara University (Date 22/04/2024/No: İ03-257-24). Consent to participate: Informed consent was obtained from all individual participants included in the study. Availability of data and materials: The datasets analyzed during the current study are not publicly available but can be obtained from the corresponding author upon reasonable request. Funding and competing interest declarations: The authors have no relevant financial or non-financial interests to disclose. Authors' contributions: All authors have substantially contributed to the conception or design of the study, or to the acquisition, analysis, or interpretation of data. They have been actively involved in drafting the manuscript or critically revising it for important intellectual content. Each author has reviewed and given final approval to the version submitted for publication. Furthermore, all authors agree to be accountable for all aspects of the work, ensuring that any questions related to the accuracy or integrity of any part of the study are thoroughly investigated and appropriately resolved. Conceptualization , O.E.B, U.B; Methodology , U.B, O.E.B, E.D; Investigation , O.E.B, U.B, M.M.C, M.A; Formal Analysis , E.D.; Resources , U.B, O.E.B, M.M.C, M.A; Writing - Original Draft , U.B, O.E.B.; Writing - Review & Editing , M.A.; Visualization , O.E.B., M.M.C.; Supervision , M.A.; Funding Acquisition , M.A. References Ogrodzka-Ciechanowicz K, Kurzeja P, Sorysz T. Assessment of Isokinetics and Range of Motion of the Shoulder in Patients after Reverse Shoulder Arthroplasty in the Late Follow-Up Period. J Clin Med, 2023. 12(23). Drake GN, O'Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010;468(6):1526–33. Nwakama AC, et al. Semiconstrained total shoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing. J Shoulder Elb Surg. 2000;9(4):302–7. Ek ET, et al. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elb Surg. 2013;22(9):1199–208. Wellmann M, et al. Short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology. Arch Orthop Trauma Surg. 2013;133(4):463–71. Ersen A, et al. Isokinetic Evaluation of Shoulder Strength and Endurance after Reverse Shoulder Arthroplasty: A Comparative Study. Acta Orthop Traumatol Turc. 2019;53(6):452–6. Edwards TB, et al. Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty. J Shoulder Elb Surg. 2009;18(6):892–6. Werner BC, et al. Glenoid lateralization influences active internal rotation after reverse shoulder arthroplasty. J Shoulder Elb Surg. 2021;30(11):2498–505. Clark JC, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elb Surg. 2012;21(1):36–41. Grassi FA, Zorzolo I. Reverse shoulder arthroplasty without subscapularis repair for the treatment of proximal humeral fractures in the elderly. Musculoskelet Surg. 2014;98(Suppl 1):5–13. Maruvada S, Madrazo-Ibarra A, Varacallo M. Anatomy, Rotator Cuff , in StatPearls . Treasure Island (FL); 2024. Pandey V, Jaap W, Willems. Rotator cuff tear: A detailed update. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(1):1–14. Ladermann A, et al. Effect of humeral stem and glenosphere designs on range of motion and muscle length in reverse shoulder arthroplasty. Int Orthop. 2020;44(3):519–30. Mitsukane M, et al. Normalized hand-behind-back for the measurement of shoulder internal rotation. JSES Int. 2022;6(2):287–91. Schwartz A, Karas S. Arthroscopic repair of an isolated teres minor tear with associated posterior glenohumeral ligament avulsion. JSES Open Access. 2018;2(2):133–6. Franceschi F, et al. Reverse shoulder arthroplasty: State-of-the-art. J ISAKOS. 2023;8(5):306–17. Hermena S, Rednam M. Reverse Shoulder Arthroplasty , in StatPearls . Treasure Island (FL); 2024. Roche CP. Reverse Shoulder Arthroplasty Biomechanics. J Funct Morphol Kinesiol, 2022. 7(1). Boileau P, et al. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elb Surg. 2005;14(1 Suppl S):S147–61. Grammont PM, Baulot E. The classic: Delta shoulder prosthesis for rotator cuff rupture. 1993. Clin Orthop Relat Res. 2011;469(9):2424. Kany J, et al. The main cause of instability after unconstrained shoulder prosthesis is soft tissue deficiency. J Shoulder Elb Surg. 2017;26(8):e243–51. Louie PK, et al. Subscapularis Tenotomy Versus Lesser Tuberosity Osteotomy for Total Shoulder Arthroplasty: A Systematic Review. Am J Orthop (Belle Mead NJ). 2017;46(2):E131–8. Shields E, Ho A, Wiater JM. Management of the subscapularis tendon during total shoulder arthroplasty. J Shoulder Elb Surg. 2017;26(4):723–31. Friedman RJ, et al. Comparison of reverse total shoulder arthroplasty outcomes with and without subscapularis repair. J Shoulder Elb Surg. 2017;26(4):662–8. Oak SR, et al. Patient reported outcomes and ranges of motion after reverse total shoulder arthroplasty with and without subscapularis repair. JSES Int. 2022;6(6):923–8. Herrmann S, et al. Reverse shoulder arthroplasty leads to significant biomechanical changes in the remaining rotator cuff. J Orthop Surg Res. 2011;6:42. Routman HD. The role of subscapularis repair in reverse total shoulder arthroplasty. Bull Hosp Jt Dis (2013), 2013. 71 Suppl 2: pp. 108 – 12. Wu JG, Bordoni B. Anatomy, Shoulder and Upper Limb, Scapulohumeral Muscles , in StatPearls . Treasure Island (FL); 2024. Namdari S, et al. Defining functional shoulder range of motion for activities of daily living. J Shoulder Elb Surg. 2012;21(9):1177–83. de Boer FA, van Kampen PM, Huijsmans PE. The influence of subscapularis tendon reattachment on range of motion in reversed shoulder arthroplasty: a clinical study. Musculoskelet Surg. 2016;100(2):121–6. Chang LR, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Glenohumeral Joint , in StatPearls . Treasure Island (FL); 2024. Bezirgan U, et al. Repairability of the subscapularis tendon in reverse shoulder prosthesis according to radiological findings. Shoulder & Elbow; 2024. Bauer S et al. Lateralization in Reverse Shoulder Arthroplasty. J Clin Med, 2021. 10(22). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6369611","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":460281455,"identity":"dad3ae95-af43-4bf4-85f5-e0d4ded07865","order_by":0,"name":"Orhun Eray Bozkurt","email":"","orcid":"","institution":"Kulu Region State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Orhun","middleName":"Eray","lastName":"Bozkurt","suffix":""},{"id":460281458,"identity":"d5ec4482-d7ce-4876-96b4-16d38e991a60","order_by":1,"name":"Ugur Bezirgan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYJACZiDmAbM+ADEbOylaGGeAtDATqQXC4EHh4gAG59eYfS6oqJMx71/87LHNr23yfMwMjB8+5uDRcuON8ewZZ9h4ZG48MzfO7btt2MbMwCw5cxs+LWeMmXnbeHgkJA6YSef23GYEamFj5iWo5Z8EUMvxb9KWPbftCWs53wPU0mDAI8HfYybN8ON2IkEtkjfYiplnHEsA2sJTJtnbcDu5jZmxGa9f+M4f3sxcUFNnL8F/fJvEjz+3bee3Nx/88BGPFgaJBCQGYxuIxdiARz0Q8B9AZvzBr3gUjIJRMApGJgAAqehKBGVtrKoAAAAASUVORK5CYII=","orcid":"","institution":"Ankara University Faculty of Medicine, Orthopaedics and traumatology department","correspondingAuthor":true,"prefix":"","firstName":"Ugur","middleName":"","lastName":"Bezirgan","suffix":""},{"id":460281459,"identity":"06ad2ade-9814-49b3-96ec-7b13b21fb38e","order_by":2,"name":"Mehmet Mesut Celebi","email":"","orcid":"","institution":"Ankara University Faculty of Medicine, Sports medicine department","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Mesut","lastName":"Celebi","suffix":""},{"id":460281462,"identity":"3ca46528-3968-406c-a9f0-4fbd4721303f","order_by":3,"name":"Ebru Dumlupinar","email":"","orcid":"","institution":"Ankara University Faculty of Medicine, Biostatistics department","correspondingAuthor":false,"prefix":"","firstName":"Ebru","middleName":"","lastName":"Dumlupinar","suffix":""},{"id":460281463,"identity":"d6ab5951-6d0e-44f9-8c7d-97b228f2d339","order_by":4,"name":"Mehmet Armangil","email":"","orcid":"","institution":"Ankara University Faculty of Medicine, Orthopaedics and traumatology department","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Armangil","suffix":""}],"badges":[],"createdAt":"2025-04-03 13:08:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6369611/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6369611/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83421030,"identity":"cc680570-558a-4a4e-af72-dca7153780e3","added_by":"auto","created_at":"2025-05-26 01:58:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130889,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAxial force couple\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSc:\u003cstrong\u003e \u003c/strong\u003eSubscapularis muscle, I/Tm:\u003cstrong\u003e \u003c/strong\u003eInfraspinatus/ Teres minör muscles\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6369611/v1/00b13297e1faf439f1617a28.png"},{"id":83421038,"identity":"c1efa724-b58d-46a5-8b20-84274897184e","added_by":"auto","created_at":"2025-05-26 01:58:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":102577,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6369611/v1/1702e53d65a73a8c03a1aa0b.png"},{"id":83421036,"identity":"8391ab49-da0e-4ac4-80e6-83a879393bcc","added_by":"auto","created_at":"2025-05-26 01:58:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":376004,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative isokinetic and endurance assessment of shoulder rotation in reverse arthroplasty patients using a dynamometer\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6369611/v1/a8bb212fb89414f0460ef526.png"},{"id":83421044,"identity":"3f04fdc9-bea1-4d25-aaf7-68eac3e7feab","added_by":"auto","created_at":"2025-05-26 01:58:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":106174,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGlobal offset measurement\u003c/strong\u003e( The distance between line A and line B. Line A is the vertical linepassing throughthe bone-glenoid baseplate interface. Line B is vertical line passing through the middle of the diaphysis of the humeral stem)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6369611/v1/634c11b8ce6425c2b59e0f20.png"},{"id":86704370,"identity":"4286a6a7-1db2-4051-af1a-298da5eb4367","added_by":"auto","created_at":"2025-07-14 17:01:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1600866,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6369611/v1/05d38c93-21fd-43b4-be2e-d39b3cdb2a6f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Influence Of Rotator Cuff Muscles And Lateralization On Internal And External Rotation In Reverse Shoulder Arthroplasty","fulltext":[{"header":"Introduction","content":"\u003cp\u003eReverse shoulder arthroplasty (RSA) has gained popularity in recent years and its use has increased for the treatment of osteoarthritis resulting from rotator cuff deficiency. It is an effective treatment method for relieving preoperative pain and improving functional capacity in patients [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. RSA also allows for the restoration of the rotator cuff muscles and supports shoulder balance [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Additionally, one of the mechanisms of RSA is to increase shoulder abduction by extending the deltoid moment arm and medializing the center of rotation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although there is data in the literature regarding shoulder abduction in RSA, there is a lack of clear information on internal and external rotation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The repair of the subscapularis muscle after RSA continues to be a debated topic in the literature. Some publications suggest that the repair of the subscapularis in RSA increases anterior stability and contributes to functional internal rotation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], while others state that repairing the subscapularis muscle does not have a positive contribution in the postoperative period [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, the gains in rotational functional movements in daily life in these patients during the postoperative period remain controversial [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe anterior rotator cuff muscles (subscapularis) and the posterior rotator cuff muscles (infraspinatus and teres minor) influence internal and external rotation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The presence and functionality of the subscapularis, teres minor, and infraspinatus muscles, which contribute to internal and external rotation movements in the rotator cuff muscles, affect the daily rotational movements of patients. Additionally, the balanced moment between the subscapularis and infraspinatus-teres minor muscles is referred to as the transverse force couple. Deficiency in these muscles leads to an imbalance in the force couple and disrupts stability [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe aim of this study is to evaluate how much the presence of anterior and posterior rotator cuff muscles affects internal and external rotational functional movements by examining their isokinetic and endurance values. Although isokinetic and endurance evaluations have been conducted in patients undergoing RSA, there is no study showing the relationship between these evaluations and the presence of each of the rotator cuff muscles.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e The study protocol was approved by the University Medical Faculty Human Studies Institutional Ethics Review Board (ID: İ03-257-24 ). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003cp\u003eThirty-one patients who underwent surgery for rotator cuff arthropathy in our clinic between 2020\u0026ndash;2023 were retrospectively included in the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Patients who underwent surgery for rotator cuff tear arthropathy, who had at least a year of follow-up, and who received inlay reverse shoulder arthroplasty were included in the study. Patients who underwent revision reverse shoulder arthroplasty, those who received reverse shoulder prostheses due to tumors or fractures, those who underwent onlay reverse shoulder arthroplasty, patients with follow-up of less than a year, and those with inflammatory arthropathy were excluded from the study.\u003c/p\u003e \u003cp\u003eAll patients were evaluated by the same doctor (M.\u0026Ccedil;) using the Biodex System 4 Isokinetic Dynamometer (Biodex Medical Systems, Shirley NY, 11967, USA) after a year postoperatively. Patients, while seated with the elbow at 90\u0026deg; flexion, had their shoulder internal and external rotation isokinetic strength and endurance measured. The average peak torque (nm) at a speed of 60\u0026deg;/sec over five repetitions was determined to measure muscle strength. The total work (nm) at a speed of 180\u0026deg;/sec over ten repetitions was determined to measure muscle endurance (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe degree of lateralization (global offset) was measured from postoperative shoulder X-rays (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, the range of motion (ROM) for internal rotation was measured by the level reached by the thumb on the back [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], while the ROM for external rotation was measured using a universal standard goniometer. All patients were also assessed preoperatively and postoperatively with the Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), and Constant score.\u003c/p\u003e \u003cp\u003eWe used the deltopectoral approach during surgery. The supraspinatus muscle was routinely excised. Glenoid version was set to a standard 20\u0026deg; retroversion. During the intraoperative period, we repaired the subscapularis muscle with non-absorbable sutures whenever possible. During surgery, we assessed the tension and passive ROM of the subscapularis muscle after intraoperative repair. In cases where it was tense, we did not repair the subscapularis to avoid negatively affecting the function of the external rotator muscles or not to reduce the abductor power of the deltoid by an antagonistic effect.\u003c/p\u003e \u003cp\u003eThe integrity of the teres minor and infraspinatus muscles was evaluated preoperatively using magnetic resonance imaging (MRI), while intraoperative repair information of the subscapularis was obtained from surgical reports. Patients were divided into four groups based on the presence of these muscles: Group A included patients with a repaired subscapularis and intact teres minor/infraspinatus, Group B included patients with a repaired subscapularis and non-intact teres minor/infraspinatus, Group C included patients with a non-repaired subscapularis and intact teres minor/infraspinatus, and Group D included patients with a non-repaired subscapularis and non-intact teres minor/infraspinatus.\u003c/p\u003e \u003cp\u003eDescriptive statistics were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for the variables distributed normally and as median (min, max, IQR) for the variables distributed not normally, whereas they were presented as number and percentage (%) for nominal variables. The significance of the difference between the groups in terms of the median values was analyzed by Kruskal Wallis Test. The relationship between variables was evaluated by Spearman\u0026rsquo;s Rho Correlation Test. For the levels of the correlation coefficients, 0-0.19 no correlation, 0.40\u0026ndash;0.59 moderate correlation, 0.60\u0026ndash;0.79 strong correlation, 0.80-1 very strong correlation were used asthe basis for interpretation. A p value of less than 0.05 was considered statistically significant and the analyses were conducted using the Statistical Package for Social Sciences (SPSS, Version 15.0, Chicago, IL). In terms of isokinetic (ER), the total minimum number of participants required for the study to detect an effect size of 0.68 (Cohen's f) with a significance level of 0.05 and a power of 0.80 among the groups (A, B, C, D) in a 2:1:1:1 ratio is 28. The sample size calculation was performed using G*Power (version 3.1.9.4) with the 'Many groups: ANOVA: One-way' option. The imbalance in sample size is due to the unequal distribution of the groups, resulting from the fact that tears in the teres minor muscle are a rare type [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe 31 patients included in the study had an average age of 73.77\u0026thinsp;\u0026plusmn;\u0026thinsp;8.42 years, and 26 of them (83.9%) were female. The demographic and clinical characteristics of the patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Radiological and functional parameters are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There were no significant differences in internal and external rotation ROM differences between the preoperative and postoperative periods among the groups (p\u0026thinsp;=\u0026thinsp;0.118, p\u0026thinsp;=\u0026thinsp;0.175, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly, differences in VAS, Constant, and ASES scores were not significant (p\u0026thinsp;=\u0026thinsp;0.115, p\u0026thinsp;=\u0026thinsp;0.087, p\u0026thinsp;=\u0026thinsp;0.262, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eDemographic and Clinical Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, \u003cem\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.77\u0026thinsp;\u0026plusmn;\u0026thinsp;8.42\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, \u003cem\u003en (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (83.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (16.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDominant Side, \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (90.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (9.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperated Side, \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (80.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscapularis, \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (58.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (41.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeres Min\u0026ouml;r/infraspinatus, \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (61.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (38.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups, \u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (38.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (22.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eSD: Standart Deviation, IQR: Interquartile Range\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e* A: Subscapularis repaired\u0026thinsp;+\u0026thinsp;teres minor/infraspinatus intact B: Subscapularis repaired\u0026thinsp;+\u0026thinsp;teres minor/infraspinatus not intact C: Subscapularis not repaired\u0026thinsp;+\u0026thinsp;teres minor/infraspinatus intact D: Subscapularis not repaired\u0026thinsp;+\u0026thinsp;teres minor/infraspinatus not intact\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiological parameters and clinical range of motion of all patients included in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop IR ROM, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1, 5, 1)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop IR ROM, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3, 5, 2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop ER ROM, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (5, 50, 15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop ER ROM, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (20, 75, 15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGO, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.35 (2.66, 5.7, 1.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eSD: Standart Deviation, IQR: Interquartile Range,min: minimum, max:maximum, ROM: Range of Motion IR:Internal Rotation, ER: External Rotation, GO: Global Offset\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe functional scores, isokinetic strength, and endurance values of all patients included in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop VAS, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (8, 10, 1)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop VAS, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1, 6, 3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop Constant, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (10, 38, 16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop Constant, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (40, 69, 17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop ASES, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (3, 37, 23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop ASES, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (37, 65, 22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eER isokinetic, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.1 (7.9, 27.2, 9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIR isokinetic, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8 (6.3, 41.2, 19.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eER endurance, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.2 (5.5, 19.3, 3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIR endurance, \u003cem\u003emedian (min, max, IQR)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.2 (5.5, 31.8, 8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eIQR: Interquartile Range,min: minimum, max:maximum, VAS: Visual Analogue Scale, ASES: American Shoulder and Elbow Surgeons Score, IR:Internal Rotation, ER: External Rotation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe differences in postoperative/preoperative internal and external rotation ROM and functional score differences between groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eD\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDifference IR\u003c/b\u003e, \u003cb\u003emedian (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(0, 2, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(0, 2, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(1, 2, 0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(1, 2, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.118\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDifference ER\u003c/b\u003e, \u003cb\u003emedian (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(-15, 40, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.5\u003c/p\u003e \u003cp\u003e(25, 45, 12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e(25, 62, 10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e(-10, 30, 21.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.175\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDifference VAS\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003emedian (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003cp\u003e(4, 8, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(2, 8, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(3, 9, 3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(3, 7, 4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.115\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDifference Constant\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003emedian (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e(8, 50, 31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003cp\u003e(20, 45, 14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e(5, 30, 25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e(8, 43, 29.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.087\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDifference ASES\u003c/b\u003e,\u003c/p\u003e \u003cp\u003e\u003cb\u003emedian (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003cp\u003e(9, 53, 22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e(18, 50, 20.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(8, 40, 22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003cp\u003e(15, 58, 29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.262\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup A: Repaired subscapularis and intact teres minor/infraspinatus, Group B: Repaired subscapularis and non-intact teres minor/infraspinatus, Group C: Non-repaired subscapularis and intact teres minor/infraspinatus, Group D: Non-repaired subscapularis and non-intact teres minor/infraspinatus\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIQR: Interquartile Range, \u003csup\u003ea\u003c/sup\u003e Kruskal Wallis Test, min: minimum, max:maximum, VAS: Visual Analogue Scale, ASES: American Shoulder and Elbow Surgeons Score, IR:Internal Rotation, ER: External Rotation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIsokinetic and endurance values for both internal and external rotation showed significant differences among the groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Both isokinetic and endurance values were higher in Group A, regardless of internal or external rotation (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of isokinetic and endurance values between groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eC\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eD\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIsokinetic (ER), median (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.95\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(16.1, 27.2, 7.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.8\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(10.9, 12.6, 1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003csup\u003exy\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(9.6, 19.8, 7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.5\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(7.9, 9.2, 1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIsokinetic (IR), median (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.05\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(12, 41.2, 12.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u003csup\u003exy\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(14.8, 15.8, 0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(6.3, 26.3, 1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.7\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(7.2, 11, 3.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndurance (ER), median (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.85\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(9, 19.3, 5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.1\u003csup\u003exy\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(9.6, 11.1, 1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.4\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(7.7, 10.3, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.65\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(5.5, 11.6, 5.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.001\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndurance (IR), median (min, max, IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.55\u003csup\u003ey\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(11.7, 31.8, 7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.7\u003csup\u003exy\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(14.6, 15.3, 0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.6\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(5.5, 15.7, 2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.55\u003csup\u003ex\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(5.5, 10.1, 4.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGroup A: Repaired subscapularis and intact teres minor/infraspinatus, Group B: Repaired subscapularis and non-intact teres minor/infraspinatus, Group C: Non-repaired subscapularis and intact teres minor/infraspinatus, Group D: Non-repaired subscapularis and non-intact teres minor/infraspinatus\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIQR: Interquartile Range, \u003csup\u003ea\u003c/sup\u003e Kruskal Wallis Test, min: minimum, max:maximum, IR:Internal Rotation, ER: External Rotation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* The difference between medians with different character is statistically significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen examining the correlation between muscle presence and isokinetic and endurance values of internal and external rotation, a statistically significant and strongly negative correlation was found from Group A to Group D. A significant positive correlation was found between component lateralization and external rotation isokinetic and endurance values (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). A significant negative correlation was found between lateralization and internal rotation ROM difference (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe correlation of groups and lateralization with isokinetic, endurance values of internal and external rotation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIsokinetic (ER)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIsokinetic (IR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEndurance (ER)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEndurance (IR)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.687\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.757\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.344\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0.021\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.438\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e0.04\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e0.058\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003er: Spearman\u0026rsquo;s Rho Correlation Coefficient, IR:Internal Rotation, ER: External Rotation, GO: Global Offset\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe correlation of groups and lateralization with the difference in internal and external rotation ROM\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDifference IR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eDifference ER\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0.257\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.267\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-0.226\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e0.032\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.221\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003er: Spearman\u0026rsquo;s Rho Correlation Coefficient, IR:Internal Rotation, ER: External Rotation, GO: Global Offset\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe condition of the rotator cuff tendons, preoperative ROM, and patient-related factors can affect the functional outcome of RSA. In this study, we primarily focused on the impact of component lateralization and the integrity of rotator cuff tendons on the internal and external rotation outcomes. The biomechanical and functional characteristics of reverse shoulder arthroplasty have been among the most researched aspects in recent years [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These studies have particularly emphasized the function of the deltoid muscle and the abduction movement of the shoulder [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, there is a debate regarding the function of the subscapularis muscle and whether it should be repaired during surgery. Some studies suggest that the repair of the subscapularis muscle has a positive functional effect [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], while others have shown that it has no effect [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe impact of repairing the subscapularis muscle on internal and external rotation has been a topic of debate in the literature. However, there is no consensus on the effect of the subscapularis in the presence of the teres minor and infraspinatus muscles on shoulder internal and external rotation in reverse shoulder arthroplasty. In a cadaver study, significant changes were observed in the moment arms of both the teres minor and subscapularis during glenohumeral abduction. The reduced rotational moment arms due to the decreased origo-insertion distance of the muscles may be a possible explanation for the clinically observed deficiencies in external and internal rotation [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In a study by Erşen et al., the endurance and isokinetic values in rotational movements were found to be significantly lower in patients undergoing reverse shoulder arthroplasty compared to the contralateral shoulder, supporting this cadaver study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In their study, the subscapularis muscle was repaired in all cases, but the teres minor and infraspinatus muscles were not evaluated. In this study, the contralateral shoulder was not evaluated, assuming a high risk of rotator cuff disease in it as well. Patients were examined by categorizing each muscle of the cuff separately before and after surgery. All isokinetic and endurance values for internal and external rotation were higher in Group A. This suggests that better rotational functional results can be obtained in shoulders closer to primary anatomy. Some studies suggest that the repair of the subscapularis muscle may negatively affect external rotation function [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], in this study, we found that, in addition to the presence of the teres minor muscle, repairing the subscapularis muscle (i.e., Group A) had a positive effect on external rotation isokinetic strength and endurance.\u003c/p\u003e \u003cp\u003eIn our study, the differences in ROM and functional scores between preoperative and postoperative periods were not significant in any group. This suggests that the prosthesis design in reverse shoulder arthroplasty provides sufficient improvement for daily activities regardless of the presence of the rotator cuff muscles. Additionally, it is known that the anterior and posterior fibers of the deltoid muscle, with improved function, make a significant contribution to the shoulder's internal and external rotation functions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study involving 15 patients who underwent reverse shoulder arthroplasty and a control group of 15 healthy subjects, the operated shoulder was compared with both the contralateral shoulder and the shoulders of healthy subjects. It was found that the ROM for flexion, extension, and abduction, as well as the isokinetic values for flexion, extension, abduction, and adduction, were all lower in the operated shoulder [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the shortcoming of this study is the lack of evaluation of internal and external rotation. It is known that rotational movements are important for daily activities and tasks [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In this study, although postoperative ROM values improved in all groups, no significant difference was observed between the groups. Contrary to the literature, a negative correlation was found between internal rotation and prosthesis lateralization, while no correlation was found between external rotation and lateralization. This situation can be explained by the relative tension of the repaired subscapularis as the prosthesis becomes more lateralized, significantly reducing its function, or by its rerupture in the postoperative period. Additionally, it can be said that the subscapularis, which cannot be sutured due to lateralization, also reduces internal rotation ROM.\u003c/p\u003e \u003cp\u003eIn a study by De Boer et al., it was found that only ten (40%) of 25 patients who underwent reverse shoulder arthroplasty with repaired subscapularis had an intact subscapularis on control ultrasound at an average follow-up of 30 months [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This result shows that a portion of the repaired subscapularis muscles did not heal or reruptured. In our clinical experience, we do not repair subscapularis muscles that can be sutured intraoperatively but are tense due to the risk of rerupture in the postoperative period and because it may reduce external rotation and abduction. In this case, we try to achieve better internal and external rotation by using more lateralized components. Additionally, it has been shown that the anterior fibers of the deltoid muscle also contribute to internal rotation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Studies have shown that lateralization does not affect the ability to suture, but distalization does [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. If there is no muscle that can be sutured during surgery, we can compensate this with component lateralization [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough postoperative isokinetic and endurance values for internal and external rotation were significantly different between the groups, the differences in functional scores compared to the preoperative period were not significant between the groups. However, this study showed us that isokinetic and endurance parameters maybe still important in RSA. This is because daily activities include movements that require repetitive or maximum power usage. A study with a larger sample size could provide more valuable information.\u003c/p\u003e \u003cp\u003eThe limitations of our study include the small sample size and the retrospective nature of the study. Studying the preoperative isokinetic and endurance values of patients would have made this study better for comparison purposes. Additionally, it is evident that the gender of the patients and the dominance of the operated side also affect the results. Additionally, the postoperative integrity of the subscapularis muscle in patients who underwent repair was not evaluated. Postoperative follow-up with MRI or ultrasound could have been useful for assessing rerupture.\u003c/p\u003e \u003cp\u003eThe strength of this study is that it sheds light on the future by examining the relationship between reverse shoulder arthroplasty, internal and external rotation ROM, isokinetic and endurance values, rotator cuff muscles, and component lateralization.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe ability to repair the subscapularis in the presence of the teres minor and infraspinatus has the most positive effect on the rotational movements of the shoulder. Thus, this force couple in the rotator cuff is effective even in anatomically unconventional reverse shoulder prosthesis. Additionally, component lateralization has a positive effect on the shoulder's external rotation endurance and isokinetic values.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e:\u0026nbsp;not applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Ankara University (Date 22/04/2024/No: İ03-257-24).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eInformed consent was obtained from all individual participants included in the study.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets analyzed during the current study are not publicly available but can be obtained from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFunding and competing interest declarations:\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: All authors have substantially contributed to the conception or design of the study, or to the acquisition, analysis, or interpretation of data. They have been actively involved in drafting the manuscript or critically revising it for important intellectual content. Each author has reviewed and given final approval to the version submitted for publication. Furthermore, all authors agree to be accountable for all aspects of the work, ensuring that any questions related to the accuracy or integrity of any part of the study are thoroughly investigated and appropriately resolved.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConceptualization\u003c/em\u003e, O.E.B, U.B; \u003cem\u003eMethodology\u003c/em\u003e, U.B, O.E.B, E.D; \u003cem\u003eInvestigation\u003c/em\u003e, O.E.B, U.B, \u0026nbsp;M.M.C, M.A; \u003cem\u003eFormal Analysis\u003c/em\u003e, E.D.; \u003cem\u003eResources\u003c/em\u003e, U.B, O.E.B, M.M.C, M.A; \u003cem\u003eWriting - Original Draft\u003c/em\u003e, U.B, O.E.B.; \u003cem\u003eWriting - Review \u0026amp; Editing\u003c/em\u003e, M.A.; \u003cem\u003eVisualization\u003c/em\u003e, O.E.B., M.M.C.; \u003cem\u003eSupervision\u003c/em\u003e, M.A.; \u003cem\u003eFunding Acquisition\u003c/em\u003e, M.A.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOgrodzka-Ciechanowicz K, Kurzeja P, Sorysz T. Assessment of Isokinetics and Range of Motion of the Shoulder in Patients after Reverse Shoulder Arthroplasty in the Late Follow-Up Period. J Clin Med, 2023. 12(23).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrake GN, O'Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010;468(6):1526\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNwakama AC, et al. Semiconstrained total shoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing. J Shoulder Elb Surg. 2000;9(4):302\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEk ET, et al. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elb Surg. 2013;22(9):1199\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWellmann M, et al. Short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology. Arch Orthop Trauma Surg. 2013;133(4):463\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErsen A, et al. Isokinetic Evaluation of Shoulder Strength and Endurance after Reverse Shoulder Arthroplasty: A Comparative Study. Acta Orthop Traumatol Turc. 2019;53(6):452\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdwards TB, et al. Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty. J Shoulder Elb Surg. 2009;18(6):892\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerner BC, et al. Glenoid lateralization influences active internal rotation after reverse shoulder arthroplasty. J Shoulder Elb Surg. 2021;30(11):2498\u0026ndash;505.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark JC, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elb Surg. 2012;21(1):36\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrassi FA, Zorzolo I. Reverse shoulder arthroplasty without subscapularis repair for the treatment of proximal humeral fractures in the elderly. Musculoskelet Surg. 2014;98(Suppl 1):5\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaruvada S, Madrazo-Ibarra A, Varacallo M. \u003cem\u003eAnatomy, Rotator Cuff\u003c/em\u003e, in \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL); 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePandey V, Jaap W, Willems. Rotator cuff tear: A detailed update. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(1):1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLadermann A, et al. Effect of humeral stem and glenosphere designs on range of motion and muscle length in reverse shoulder arthroplasty. Int Orthop. 2020;44(3):519\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitsukane M, et al. Normalized hand-behind-back for the measurement of shoulder internal rotation. JSES Int. 2022;6(2):287\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchwartz A, Karas S. Arthroscopic repair of an isolated teres minor tear with associated posterior glenohumeral ligament avulsion. JSES Open Access. 2018;2(2):133\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranceschi F, et al. Reverse shoulder arthroplasty: State-of-the-art. J ISAKOS. 2023;8(5):306\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHermena S, Rednam M. \u003cem\u003eReverse Shoulder Arthroplasty\u003c/em\u003e, in \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL); 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoche CP. Reverse Shoulder Arthroplasty Biomechanics. J Funct Morphol Kinesiol, 2022. 7(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoileau P, et al. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elb Surg. 2005;14(1 Suppl S):S147\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrammont PM, Baulot E. The classic: Delta shoulder prosthesis for rotator cuff rupture. 1993. Clin Orthop Relat Res. 2011;469(9):2424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKany J, et al. The main cause of instability after unconstrained shoulder prosthesis is soft tissue deficiency. J Shoulder Elb Surg. 2017;26(8):e243\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLouie PK, et al. Subscapularis Tenotomy Versus Lesser Tuberosity Osteotomy for Total Shoulder Arthroplasty: A Systematic Review. Am J Orthop (Belle Mead NJ). 2017;46(2):E131\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShields E, Ho A, Wiater JM. Management of the subscapularis tendon during total shoulder arthroplasty. J Shoulder Elb Surg. 2017;26(4):723\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriedman RJ, et al. Comparison of reverse total shoulder arthroplasty outcomes with and without subscapularis repair. J Shoulder Elb Surg. 2017;26(4):662\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOak SR, et al. Patient reported outcomes and ranges of motion after reverse total shoulder arthroplasty with and without subscapularis repair. JSES Int. 2022;6(6):923\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerrmann S, et al. Reverse shoulder arthroplasty leads to significant biomechanical changes in the remaining rotator cuff. J Orthop Surg Res. 2011;6:42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoutman HD. \u003cem\u003eThe role of subscapularis repair in reverse total shoulder arthroplasty.\u003c/em\u003e Bull Hosp Jt Dis (2013), 2013. 71 Suppl 2: pp. 108\u0026thinsp;\u0026ndash;\u0026thinsp;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu JG, Bordoni B. \u003cem\u003eAnatomy, Shoulder and Upper Limb, Scapulohumeral Muscles\u003c/em\u003e, in \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL); 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNamdari S, et al. Defining functional shoulder range of motion for activities of daily living. J Shoulder Elb Surg. 2012;21(9):1177\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Boer FA, van Kampen PM, Huijsmans PE. The influence of subscapularis tendon reattachment on range of motion in reversed shoulder arthroplasty: a clinical study. Musculoskelet Surg. 2016;100(2):121\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang LR, Anand P, Varacallo M. \u003cem\u003eAnatomy, Shoulder and Upper Limb, Glenohumeral Joint\u003c/em\u003e, in \u003cem\u003eStatPearls\u003c/em\u003e. Treasure Island (FL); 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBezirgan U, et al. Repairability of the subscapularis tendon in reverse shoulder prosthesis according to radiological findings. Shoulder \u0026amp; Elbow; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauer S et al. Lateralization in Reverse Shoulder Arthroplasty. J Clin Med, 2021. 10(22).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Reverse shoulder arthroplasty, isokinetic, endurance, subscapularis, teres minör","lastPublishedDoi":"10.21203/rs.3.rs-6369611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6369611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The subscapularis and its antagonist muscles, the infraspinatus-teres minor, affect functional rotational movements in daily life. A deficiency in either of these muscles leads to a strength imbalance. In patients undergoing reverse shoulder arthroplasty (RSA), the repair of the subscapularis muscle is a debated topic. This study aimed to determine the relationship between the isokinetic and endurance values of internal and external rotation in patients post-RSA, and the presence of this muscle pair and lateralization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Thirty-one patients who underwent RSA between 2020-2023 were retrospectively included in the study. Isokinetic and endurance values were measured using a dynamometer device. Lateralization was calculated from postoperative X-ray images by determining the global offset . Patients’ Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), and Constant scores were measured, and range of motion (ROM) was evaluated. Based on the presence of the subscapularis and infraspinatus-teres minor muscles, patients were divided into four groups (Group A, B, C, D).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Isokinetic and endurance values for both internal and external rotation were significantly higher in Group A. There was a significant and strongly negative correlation between the presence of these muscles for isokinetic and endurance values of internal and external rotation from Group A to Group D. A significant positive correlation was found between component lateralization and isokinetic and endurance values of external rotation. A significant negative correlation was identified between lateralization and internal rotation ROM difference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The presence of the force couple in the post-RSA period positively impacts the isokinetic and endurance values of shoulder rotational movements.\u003c/p\u003e","manuscriptTitle":"The Influence Of Rotator Cuff Muscles And Lateralization On Internal And External Rotation In Reverse Shoulder Arthroplasty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-26 01:58:46","doi":"10.21203/rs.3.rs-6369611/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1dbf7ff8-cfb6-4ef0-9c70-2942817b3203","owner":[],"postedDate":"May 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T16:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-26 01:58:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6369611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6369611","identity":"rs-6369611","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}