Journal of Shoulder and Elbow Surgery

Journal of Shoulder and Elbow Surgery

Comparison of outcomes of 2 surgical treatments for proximal humerus giant cell tumors: a multicenter retrospective study

06-07-2019 – Wen-zhe Bai, Shi-bing Guo, Wei Zhao, Xiu-chun Yu, Ming Xu, Kai Zheng, Yong-cheng Hu, Feng Wang, Guo-chuan Zhang

Journal Article

The incidence of giant cell tumors in the proximal humerus is low. We evaluated 2 surgical treatments for giant cell tumors of the proximal humerus and postoperative upper-extremity function. This study retrospectively analyzed the clinical data of 27 cases of giant cell tumors of the proximal humerus at 4 Chinese medical centers specializing in bone oncology collected between January 2002 and June 2015. All patients were followed up for more than 2 years. The surgical procedures performed for treatment included curettage in 14 patients and segmental resection in 13. The Campanacci grade, occurrence of pathologic fracture, surgical method, complications, and Musculoskeletal Tumor Society score were recorded for each cohort. The recurrence rate was 7.1% in the curettage group and 15.4% in the segmental resection group. Other postoperative complications occurred in 4 patients with segmental resection, including resorption of the osteoarticular allograft in 2, subluxation of the glenohumeral joint in 1, and prosthetic loosening and exposure in 1. A significant difference in postoperative upper-extremity function was noted between the 2 groups (P < .001). Postoperative upper-extremity function in the curettage group was significantly better than that in the segmental resection group. Segmental resection and reconstruction with a large segmental osteoarticular allograft were considered unadvisable. We suggest that extensive curettage should be selected to treat proximal humerus giant cell tumors as much as possible.

All-arthroscopic, guided Eden-Hybbinette procedure using suture-button fixation for revision of failed Latarjet

25-07-2019 – Pascal Boileau, Christophe Duysens, David Saliken, Devin B. Lemmex, Nicolas Bonnevialle

Journal Article

To report the results of a guided arthroscopic Eden-Hybbinette procedure, using suture button for iliac crest bone graft fixation, in a series of patients with a prior failed Latarjet and persistent glenoid bone loss. Seven consecutive patients (5 males, 2 females, mean age: 30.7 years [range, 17-47 years]) with recurrent anterior dislocations and glenoid deficiency greater than 20% underwent the all-arthroscopic revision procedure. The iliac crest bone graft and suture-button device (Bone-Link) were shuttled through the rotator interval. Specific drill guides were used and a suture tensioning device allowed bone graft compression. Previous broken screw shafts (3 patients) were left in situ. Graft placement and healing was assessed postoperatively with computed tomography imaging. No neurologic injury or hardware problems occurred, and no patient required further surgery. On computed tomography scan, optimal positioning (flush and under the equator) and healing of the bone graft was observed in all patients. At a mean follow-up of 21 months (range, 12-39 months), all but one patient were satisfied and had a stable shoulder; 5 returned to sports. The Constant score increased from 32 to 81 points, and the subjective shoulder value from 31% to 87% (P < .001). The Walch-Duplay and Rowe scores averaged 85.7 (range, 65-100) points and 86.4 (range, 70-100) points, respectively. Recurrence of anterior shoulder instability after a failed Latarjet procedure can be successfully treated by an all-arthroscopic Eden-Hybbinette procedure. Suture-button fixation is reliable and permits optimal positioning and predictable healing of the new bone graft; in addition, it is an appropriate fixation option in the setting of retained broken hardware.

Transverse ligament of the elbow joint: an anatomic study of cadavers

17-07-2019 – Kentaro Kimata, Masaya Yasui, Hiroki Yokota, Shuichi Hirai, Munekazu Naito, Takashi Nakano

Journal Article

The medial collateral ligament of the elbow joint consists of the anterior oblique ligament (AOL), posterior oblique ligament (POL), and transverse ligament (TL). This study aimed to clarify the structure of the TL, with a focus on the continuity between the TL and AOL. A total of 42 cadavers (18 males, 24 females) were dissected at Aichi Medical University between 2016 and 2018. Cases of elbow deformity or atrophy were excluded, and 60 elbows (15 males, 15 females) were dissected to assess the fibers of both the TL and AOL using a stereomicroscope. The TL could be detected in all elbows and always continued to the AOL. The TL was classified into 2 types. The TLs continuing to the distal half of the AOL (type I) were observed in 44 elbows (73.3%), whereas the TLs continuing to the entire AOL (type II) were found in 16 elbows (26.7%). Type II TLs were significantly more frequently observed in the elbows of females than in those of males (P = .041). Stereomicroscopic observation revealed that the TL fibers entered perpendicularly to the distal half of the AOL in both types. The TL frequently continues to the distal half of the AOL, but rarely continues to the entire AOL. The TLs continuing to the entire AOL were more frequently detected in the elbows of females than in those of males. The TL possibly contributes to medial elbow stability via its continuity to the AOL.

Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace

29-07-2019 – David L. Bernholt, Spencer P. Lake, Ryan M. Castile, Christopher Papangelou, Oliver Hauck, Matthew V. Smith

Journal Article

Current ulnar collateral ligament (UCL) reconstruction techniques are substantially less stiff and demonstrate lower load to failure compared with the native UCL. UCL repair with the addition of an internal brace has demonstrated superior biomechanical performance compared with docking UCL reconstruction, but internal bracing has not yet been used in UCL reconstruction. To evaluate the time-zero biomechanical performance of a UCL docking technique reconstruction with and without an internal brace compared with native UCL properties. Twelve matched pairs of cadaveric elbows were dissected and fixed at 90° for biomechanical testing. A cyclic valgus torque protocol was used to test the anterior band of the UCL in native specimens. After native specimens were failed, palmaris grafts were used for a docking reconstruction with or without internal brace and were subjected to the same valgus torque test protocol. Torsional stiffness, ultimate failure torque, and ulnohumeral gapping were determined. Stiffness in UCL reconstructions using a standard docking technique (3.0 ± 0.4 N m/deg) were significantly less stiff (P < .001) than native UCL (4.0 ± 0.8 N m/deg), whereas reconstructions using an internal brace (3.6 ± 0.6 N m/deg) were not different (P = .120) compared with native. Ultimate failure torque for standard docking (18.3 ± 4.1 N m) was significantly lower (P < .001) than native UCL (36.9 ± 10.1 N m), whereas the internal brace samples (35.3 ± 9.8 N m) were not different (P = .772) than native. UCL reconstruction with an internal brace augmentation provides superior stiffness and time-zero failure strength when compared with the standard docking technique.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty

17-07-2019 – Anirudh K. Gowd, Michael D. Charles, Joseph N. Liu, Simon P. Lalehzarian, Brandon C. Cabarcas, Brandon J. Manderle, Gregory P. Nicholson, Anthony A. Romeo, Nikhil N. Verma

Journal Article

Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients’ sense of functional improvement after shoulder arthroplasty. Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology. A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001). The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Arthroscopic visualization of the medial collateral ligament of the elbow

14-07-2019 – Jae-Man Kwak, Erica Kholinne, Yucheng Sun, Jin-Young Park, Kyoung-Hwan Koh, In-Ho Jeon

Journal Article

This study aimed to determine the extent to which the medial collateral ligament (MCL) can be visualized during a standard posterior arthroscopic view of the elbow. Eight fresh human cadaveric elbows were placed in a simulated lateral decubitus position. Standard elbow arthroscopy was performed on each specimen using a standard posterior portal for visualization with a 30° arthroscope. The most distal borders of the visible part of the MCL were marked using a spinal needle and tagged using nylon sutures. Subsequently, the elbow was dissected. The overall surface area of the entire MCL and that defined by the suture tags were calculated for each specimen. The mean area of the visible part of the MCL represented 48% of the mean overall area. The arthroscopically tagged part of the posterior band of the MCL represented <50% of the entire MCL. Arthroscopic visualization was not available for most of the posterior bands of the MCL. Less than half of the MCL is visible with a 30° arthroscope from standard posterior portal. Thus, sole reliance on arthroscopic visualization with this manner is not enough to release of the MCL. The variable effort is required to improve the limited visualization during the procedure. Moreover, the individual attention is essential to protect the ulnar nerve because the ulnar nerve is very close to the MCL especially to the anterior band.

Development of a clinical risk calculator for prolonged opioid use after shoulder surgery

08-07-2019 – Allen D. Nicholson, Hafiz F. Kassam, Jacqueline L. Steele, Natalie R. Passarelli, Theodore A. Blaine, David Kovacevic

Journal Article

Understanding risk factors associated with prolonged opioid use to help mitigate abuse and develop presurgical screening programs to identify at-risk patients is paramount. The purpose of this study was to develop and validate a clinical risk assessment tool to preoperatively predict prolonged opioid use after shoulder surgery. A total of 561 patients who underwent shoulder surgery within a tertiary health care system were identified, and opioid prescription data were retrospectively collected from the Connecticut Prescription Monitoring and Reporting System. The inclusion criteria were patients aged 18 years or older, and the exclusion criteria were patients not registered in the Connecticut Prescription Monitoring and Reporting System. Quantities of opioids prescribed were documented. Demographic characteristics, surgery type, medications, and medical comorbidities were identified by chart abstraction. Logistic regression was used to calculate odds ratios of patients using opioids longer than 6 weeks, and multivariate analysis was performed on 10 identified patient factors. A concordance index was used to calculate the discriminatory ability of a nomogram to predict prolonged opioid use. Multivariate analysis demonstrated that opioid use prior to surgery, insurance type, procedure type, body mass index, smoking status, and psychiatric disorders were responsible for prolonged opioid use. The prediction accuracy of this model was good, with a calculated concordance index of 0.766 (95% confidence interval, 0.736-0.820). We present a preoperative predictive calculator to help identify at-risk patients and quantify their risk of prolonged opioid use after shoulder surgery. This is a valuable clinical decision-making tool to identify patients benefitting from referral to pain management specialists and to possibly reduce the risk of opioid abuse and addiction.

Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial

26-08-2019 – Niloofar Dehghan, Matthew Furey, Laura Schemitsch, Bill Ristevski, Thomas Goetz, Emil H. Schemitsch, Canadian Orthopaedic Trauma Society (COTS), Michael McKee

Journal Article

Total elbow arthroplasty (TEA) is a reliable treatment for elderly patients with comminuted intra-articular distal humeral fractures. However, the longevity and long-term complications associated with this procedure are unknown. The objectives of this study were to examine long-term outcomes and implant survival in elderly patients undergoing TEA for fracture. Patients from a previously published randomized controlled trial of 42 patients in which TEA was compared with open reduction-internal fixation (ORIF) were followed up long term. Patients were aged 65 years or older with comminuted intra-articular distal humeral fractures. Outcomes included patient-reported grading of function and pain, revision surgical procedures, and implant survival. Data were obtained for 40 patients, 15 treated with ORIF and 25 treated with TEA, with a mean follow-up period of 12.5 years for surviving patients and 7.7 years for deceased patients. The reoperation rate was 3 of 25 in the TEA group and 4 of 15 in the ORIF group (P = .39). Of the 25 patients with TEAs, only 1 required (early) revision arthroplasty; 7 were living with their original arthroplasty, and 15 died with a well-functioning implant in situ. Three were lost to follow-up. TEA is an effective and reliable procedure for the treatment of comminuted distal humeral fractures in the elderly patient. Our study reveals reliable implant long-term survival, with no patient requiring a late revision. For the majority of these patients, a well-performed TEA will give them a well-functioning elbow for life and will be the last elbow procedure required.

Latissimus dorsi transfer for massive posterosuperior rotator cuff tears: what affects the postoperative outcome?

03-07-2019 – Mohamed Moursy, Jonas Schmalzl, Aditya S. Kadavkolan, Niko Bartels, Lars-Johannes Lehmann

Journal Article

The management of irreparable posterosuperior rotator cuff tears (IPSRCTs) in young active individuals is still a challenge. The aim of this study was to evaluate the influence of sex, surgical technique, previous surgical procedures, tear genesis, and presence of a preoperative external rotation lag sign on the functional outcome after latissimus dorsi transfer (LDT) for IPSRCTs. Retrospectively, all patients with IPSRCTs treated with LDT during a 10-year period were followed up. Preoperative evaluation included the visual analog scale (VAS) score, range of motion, and the Constant score (CS). Postoperatively, the VAS score, range of motion, CS, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value were recorded. Preoperative and postoperative radiologic evaluation was performed using the Hamada-Fukuda classification and the acromiohumeral interval. In total, 67 of 79 patients (85%), with a mean age of 63 years, were available for follow-up at 54 ± 28 months. The CS improved from 24 ± 6 points preoperatively to 68 ± 17 points at follow-up (P < .001). Active flexion increased from 83° ± 47° to 144° ± 35°; abduction, from 69° ± 33° to 134° ± 42°; and external rotation, from 24° ± 18° to 35° ± 21°. Postoperatively, the Subjective Shoulder Value was 69% ± 19% and the American Shoulder and Elbow Surgeons score was 76 ± 21. The VAS score decreased from 6.3 ± 1.1 to 1.8 ± 2 (P < .001). Abduction strength increased from 0.4 ± 0.4 kg to 3.6 ± 2.2 kg (P < .001). The acromiohumeral interval decreased from 7.9 ± 2.6 mm to 5.1 ± 2.2 mm, and arthropathy worsened from Hamada-Fukuda stage 1.4 to stage 2.1. The rate of conversion to a reverse prosthesis was 6%. LDT represents a reliable and reproducible treatment option with good clinical midterm results after surgical treatment. Sex, genesis, preoperative presence of an external rotation lag sign, and previous surgical procedures do not affect the overall clinical outcome.

Radiographic outcomes of impaction-grafted standard-length humeral components in total shoulder and ream-and-run arthroplasty: is stress shielding an issue?

06-07-2019 – Patrick J. Denard, Jason E. Hsu, Anastasia Whitson, Moni B. Neradilek, Frederick A. Matsen

Journal Article

The purpose of this study was to evaluate humeral stress shielding in shoulder arthroplasties performed with a smooth, standard-length humeral stem fixed with impaction autografting. Two-year outcomes were evaluated for 48 ream-and-run arthroplasties and 78 total shoulder arthroplasties (TSAs) performed at a single institution. Postoperative radiographs were analyzed for adaptive changes, calcar osteolysis, and component shift or subsidence. Radiographic outcomes were analyzed for associations with patient demographic characteristics, humeral stem filling ratios, and glenoid loosening; clinical outcomes were assessed using the Simple Shoulder Test. At 2 years after surgery, the ream-and-run procedures showed partial calcar osteolysis in 9 cases (19%). The TSAs showed partial calcar osteolysis in 19 cases (24%) and complete calcar osteolysis in 2 (3%). Humeral component subsidence or component shift was observed in 3 ream-and-run procedures (6%) and in 8 TSAs (10%). These radiographic findings were not significantly associated with patient demographic characteristics, canal-filling ratios, or clinical outcomes. When inserted with impaction autografting, a smooth, standard-length humeral stem offers a secure bone-preserving approach for humeral component fixation in shoulder arthroplasty. These results with a conventional prosthesis can serve as a basis for comparison for new component designs and fixation methods.

Arthroscopic repair of isolated subscapularis tears: clinical outcome and structural integrity with a minimum follow-up of 4.6 years

08-07-2019 – Anita Hasler, Glenn Boyce, Alex Schallberger, Bernhard Jost, Sabrina Catanzaro, Christian Gerber

Journal Article

After isolated subscapularis repair, improvement in shoulder function has been reported at short-term review. The purpose of this study was to determine whether arthroscopic subscapularis repair provides durable improvement in objective and subjective shoulder function with a low structural retear rate. All patients treated with arthroscopic repair of an isolated subscapularis tear between August 2003 and December 2012 with a minimum follow-up period of 4.6 years were identified from our database. A number of patients in our study cohort underwent a prior complete midterm assessment, which allowed a subgroup analysis to detect changes in structural integrity and corresponding function. Clinical and radiographic outcomes, including outcomes on conventional radiography and magnetic resonance imaging or ultrasound, were assessed. The study enrolled 36 shoulders with a mean patient age of 57.7 years (range, 31-75 years; standard deviation, 10.6 years). The mean follow-up period was 8.6 years (range, 4.6-13.9 years; standard deviation, 2.44 years). Internal rotation to the thoracic vertebrae was achieved in 94% of cases and was significantly improved (P < .001) compared with the preoperative situation. The mean relative Constant score improved from 68% preoperatively to 93% at final follow-up (P < .001). Magnetic resonance imaging evaluation showed a rerupture rate of 2.7% (1 of 36 shoulders). Twenty patients underwent previous complete midterm assessment (mean, 2.9 years; range, 1-4.5 years), with comparisons between midterm and long-term follow-up showing comparable results without statistically significant deterioration. Functional and subjective improvements in shoulder function are maintained at a mean follow-up of more than 8 years after isolated subscapularis repair and are associated with a low structural failure rate of the repair.

Arthroscopic rotator cuff repair: magnetic resonance arthrogram assessment of tendon healing

13-05-2019 – Craig M. Ball

Journal Article

Many poor outcomes after arthroscopic rotator cuff (RC) repair relate to failure of tendon healing. The purposes of this study were to provide a better understanding of the magnetic resonance arthrography (MRA) characteristics of the RC tendon repair site after arthroscopic RC repair and to examine how these findings influence patient-reported outcome measures (PROMs) and the presence of persistent symptoms. We reviewed 48 shoulders (13 female and 35 male patients; average age, 53.8 years) at a minimum of 6 months (average, 11.4 months) after arthroscopic RC repair (average tear size, 2.2 cm). All patients completed PROMs and underwent MRA assessment. Detailed analysis of the RC repair site was undertaken, with findings correlated with clinical outcomes and PROMs. The average preoperative American Shoulder and Elbow Surgeons (ASES) score of 39.5 improved to 92.8 (P 50%) were observed in 7 patients (14.6%), with no effect on outcomes (average ASES score of 95.2 and satisfaction score of 9). There were 2 recurrent full-thickness tears (4.2%), and 4 patients (8.3%) had a failure in continuity. The average ASES score in these 6 cases of failure was 76 (P < .001). Structural abnormalities on MRA are common after RC repair but do not always result in clinical failure. However, our results suggest that an ASES score of less than 80 may be useful when considering postoperative imaging, especially in a patient with ongoing pain more than 6 months after surgery.

A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management

10-07-2019 – Alejandro Cortes, Noah J. Quinlan, Mark R. Nazal, Shivam Upadhyaya, Kyle Alpaugh, Scott D. Martin

Journal Article

Magnetic resonance imaging (MRI) is often used to evaluate the integrity of the rotator cuff in patients with suspected full-thickness rotator cuff tears or other cuff tendinopathies. The value of advanced imaging value comes into question when it is used as the initial musculoskeletal imaging test before a trial of conservative therapy in patients with atraumatic shoulder pain, minimal to no strength deficits on examination, and suspected cuff tendinopathy. A prospective study of a group of patients suspected to have cuff tendinopathy based on clinical findings was performed. Every patient underwent MRI and was offered an initial trial of conservative management. Patients had an average follow-up of 28.3 ± 5.3 months after imaging to determine whether surgery was performed. A total of 51 patients were included in this study. Of this cohort, 46 (90.2%) patients did not go on to surgical intervention, whereas 5 (9.8%) patients did at an average 68.3 days after imaging. These results suggest that over 90.2% of patients (46 of 51) had premature MRI, posing an unnecessary economic burden of $181,619 in advanced imaging charges. The use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits on physical examination, and suspected cuff tendinopathy other than full-thickness tears provides negative value in the management of these patients, at both the individual and population level.

Reverse total shoulder arthroplasty provides stability and better function than hemiarthroplasty following resection of proximal humerus tumors

14-08-2019 – Timothy W. Grosel, Darren R. Plummer, Joshua S. Everhart, James C. Kirven, Chance L. Ziegler, Joel L. Mayerson, Thomas J. Scharschmidt, Jonathan D. Barlow

Journal Article

Tumors may necessitate resection of a substantial portion of the proximal humerus and surrounding soft tissues, making reconstruction challenging. We evaluated outcomes in patients undergoing treatment of tumors of the proximal humerus with reverse total shoulder arthroplasty (r
TSA) or shoulder hemiarthroplasty. Patients who underwent r
TSA (n = 10) or shoulder hemiarthroplasty (n = 37) for tumors of the proximal humerus in 2009 to 2017 were reviewed. Of these patients, 27 had died, leaving 20 for review. The mean follow-up period of the survivors was 27.1 months. They were evaluated clinically and contacted to determine the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. Postoperative complications occurred in 13 hemiarthroplasty patients (34%). Tumor recurrence occurred in 3 hemiarthroplasty patients (7.9%), whereas in the r
TSA group, 1 patient (10%) had a postoperative complication, with no recurrences. One hemiarthroplasty patient required revision surgery with r
TSA to improve shoulder function. Six dislocations and two subluxations occurred in the hemiarthroplasty group, whereas no subluxations occurred in the r
TSA group (P = .14). Mean range of motion was 85° of forward flexion for r
TSA patients (n = 10) compared with 28° for hemiarthroplasty patients (P < .001). The mean American Shoulder and Elbow Surgeons score was 63 for hemiarthroplasty patients (n = 5) and 59 for r
TSA patients (n = 4). The mean Simple Shoulder Test scores were 3.8 and 2.4, respectively. The mean visual analog scale pain scores were 2.4 and 2.5, respectively. Reverse total shoulder arthroplasty can reproducibly reconstruct the shoulder in patients requiring oncologic proximal humerus resection. Patients have good outcomes, better range of motion, and no increase in instability rates compared with hemiarthroplasty.

Reverse shoulder arthroplasty for proximal humerus fracture: a more complex episode of care than for cuff tear arthropathy

14-07-2019 – Joseph N. Liu, Avinesh Agarwalla, Anirudh K. Gowd, Anthony A. Romeo, Brian Forsythe, Nikhil N. Verma, Gregory P. Nicholson

Journal Article

The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for reverse total shoulder arthroplasty (RTSA) performed because of proximal humerus fracture (PHFx) vs. cuff tear arthropathy (CTA), and determine whether acute fracture is associated with differences in complications after RTSA. The National Surgical Quality Improvement Program database was queried for RTSA performed for PHFx and CTA. This database contains surgical outcomes within 30 days after the index procedure. Patients underwent a 1:1 propensity matched based on preoperative demographics and comorbidities. Outcomes included operative time, length of stay (LOS), complications, transfusion, readmission, and discharge destination. A total of 1006 patients (503 per group) were included. With a PHFx, operative time was longer (129.5 ± 54.2 vs. 96.0 ± 40.0 minutes, P < .001), and the patients were more likely to have an adverse event (19.0% vs. 8.2%, P < .001), require transfusion (15.71% vs. 3.98%, P < .001), have longer LOS (3.8 ± 3.6 vs. 2.2 ± 1.7 days, P < .001), and were more likely to be discharged to an extended care facility (27.2% vs. 10.3%, P < .001). PHFx was an independent risk factor for an adverse event after an RTSA. RTSA to treat PHFx is associated with longer LOS, increased complications, and discharge to an extended care facility compared with RTSA for CTA. Patients with PHFx require more health care resources than patients with CTA. It is imperative for surgeons, patients, families, governments, hospital systems, and insurance payers to recognize the differences in resource utilization for RTSA in treating PHFx compared with CTA.

Medial calcar bone resorption after anatomic total shoulder arthroplasty: does it affect outcomes?

06-07-2019 – Paul DeVito, Hyrum Judd, Andy Malarkey, Leah Elson, Emmanuel McNeely, Derek Berglund, Rushabh Vakharia, Jonathan C. Levy

Journal Article

The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P = .001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P = .003) and humeral (9%, P = .039) radiolucencies. Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening.

Functional workspace and patient-reported outcomes improve after reverse and total shoulder arthroplasty

10-07-2019 – Alex Ngan, Weiyuan Xiao, Patrick F. Curran, Wo Jan Tseng, Li Wei Hung, Chantal Nguyen, Robert Matthew, Benjamin Ma, Jeffrey Lotz, Brian T. Feeley

Journal Article

Low-cost motion analysis systems (LCMASs) have emerged as easy and practical methods to measure the functional workspace (FWS). Thus, we ventured to apply an LCMAS, the Kinect2 gaming camera, to evaluate the FWS in patients with shoulder osteoarthritis (OA) and patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). A cross-sectional study of participants with OA (n = 53), TSA (n = 70), and RTSA (n = 34) was performed. The FWS as measured by an LCMAS, the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, and the Patient-Reported Outcomes Measurement Information System (PROMIS) score were collected. For participants who underwent TSA or RTSA, the FWS was evaluated at 6, 12, and 24 months postoperatively. The correlation of the FWS with the ASES score and PROMIS score was determined. Significance was set at P < .05. Patients who underwent TSA or RTSA had a significantly higher FWS than patients with shoulder OA at almost all time points. Patients who underwent TSA had a significantly higher FWS than patients who underwent RTSA at 24 months after surgery. PROMIS and ASES scores showed strong correlations with the FWS in patients who underwent TSA (R = 0.75 [P < .001] and R = 0.83 [P < .001], respectively) and RTSA (R = 0.84 [P < .001] and R = 0.73 [P < .001], respectively). The FWS measured by an LCMAS is an easy and low-cost method to quantify the reachable space of the hand in patients and shows strong correlations with patient-reported outcome measures. This may be a useful tool to assess upper-extremity range of motion before and after shoulder arthroplasty.

Predictors of unsatisfactory patient outcomes in primary reverse total shoulder arthroplasty

30-07-2019 – Michael P. Carducci, Zachary R. Zimmer, Andrew Jawa

Journal Article

Despite favorable clinical and functional results for reverse total shoulder arthroplasty (RSA), there remains a group of patients without postoperative complications who demonstrate poor improvement and overall outcome. Using a single surgeon shoulder arthroplasty registry, we identified patients who underwent RSA from 2013 to 2016 with minimum of 2-year postoperative follow-up. Patients with intra- and postoperative complications were excluded. Poor postoperative clinical outcome was defined as those patients within the bottom 30th percentile for American Shoulder and Elbow Surgeons (ASES) score. Poor postoperative improvement was defined as the bottom 30th percentile of ASES improvement, measured preoperatively to the 2-year postoperative mark. Multivariate logistic regression modeling was used to determine preoperative characteristics (e.g., demographics, comorbidities, preoperative ASES score) associated with poor outcome. A total of 137 patients met the inclusion and exclusion criteria. Multivariable logistic regression modeling found that prior shoulder surgery, the majority (75%) of which were arthroscopic, was the only independent factor associated with both poor improvement (adjusted odds ratio, 2.46 [1.03-5.83]) and outcome (adjusted odds ratio, 4.92 [1.74-14.96]). Preoperative opioid use was associated with poor outcomes only, whereas the high preoperative ASES score was associated with poor postoperative improvement. Prior ipsilateral shoulder surgery was strongly associated with poor clinical improvement and outcome after RSA. No other factors correlated with both poor improvement and outcome. This association is important to decision making for any shoulder surgery, given the long-term implications.

Preoperative corticosteroid joint injections within 2 weeks of shoulder arthroscopies increase postoperative infection risk

03-07-2019 – Sarah Bhattacharjee, Wonyong Lee, Michael J. Lee, Lewis L. Shi

Journal Article

There is currently no consensus regarding the safe timing interval between corticosteroid shoulder injections and future shoulder arthroscopies. Our study assessed the relationship between preoperative corticosteroid injection timing and shoulder arthroscopy infectious outcomes. We used an insurance database to identify and sort all shoulder arthroscopy patients by corticosteroid shoulder injection history within 6 months before surgery. Patients who received injections were stratified by the timing of their most recent preoperative injection. The overall infection rate and rate of severe infections requiring treatment through intravenous antibiotics or surgical débridement in the 6-month postoperative period were compared using χ We identified 50,478 shoulder arthroscopy patients, of whom 4115 received injections in the 6-month preoperative period. We found a significant increase in both the overall infection rate (P < .0001) and severe infection rate (P < .0001) in patients who received injections within 2 weeks before surgery (n = 79; 8.86% and 6.33%, respectively) compared with those who received no injections in the 6-month preoperative period (n = 46,363; 1.56% and 0.55%, respectively). No other significant differences were observed. Our results suggest that in patients who have received corticosteroid injections, shoulder arthroscopic procedures may be safely performed after at least 2 weeks has passed since the most recent injection to minimize the risk of postoperative infection. In addition, procedures performed within 2 weeks of an injection may increase the risk of postoperative infection.

Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness

28-08-2019 – Amr A. Abdelrahman, Amr Ibrahim, Khalid Abdelghaffar, Tarek Mohamed Ghandour, Diaa Eldib

Journal Article

The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using Tight
Rope in acromioclavicular joint dislocation III and IV. Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively. CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG). Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.

Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up

18-07-2019 – Alison I. Murphy, Eoghan T. Hurley, Daire J. Hurley, Leo Pauzenberger, Hannan Mullett

Journal Article, Review

The purpose of this study was to systematically review the evidence in the literature to ascertain the functional outcomes and recurrences rates, as well as subsequent revision rates, following arthroscopic Bankart repair at a minimum of 10 years’ follow-up. Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library databases. Studies were included if they were clinical studies on arthroscopic Bankart repair with a minimum of 10 years’ follow-up. Statistical analysis was performed using SPSS software. Our review found 9 studies including 822 shoulders meeting our inclusion criteria. The majority of patients were male patients (75.5%), the average age was 28.0 years (range, 15-73 years), and the mean follow-up period was 149.4 months. The most commonly used functional outcome score was the Rowe score, with a weighted mean of 87.0. Overall, 77.6% of athletes were able to return to sports postoperatively. The overall rate of recurrent instability was 31.2%, with 16.0% of patients having recurrent dislocations, and the overall revision rate was 17.0%. Evidence of instability arthropathy was found in 59.4% of patients, with 10.5% of patients having moderate to severe arthropathy. Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent long-term functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery. In addition, the high rate of instability arthropathy is a concern following arthroscopic Bankart repair in the long term.

Does Medicaid expansion improve access to care for the first-time shoulder dislocator?

16-09-2019 – Graham E. Kirchner, Nicholas J. Rivers, Emily F. Balogh, Samuel R. Huntley, Paul A. MacLennan, Brent A. Ponce, Eugene W. Brabston, Amit M. Momaya

Journal Article

The purpose of this study was to assess the effect of individual state Medicaid expansion status on access to care for shoulder instability. Four pairs of Medicaid expanded (Louisiana, Kentucky, Iowa, and Nevada) and unexpanded (Alabama, Virginia, Wisconsin, and Utah) states in similar geographic locations were chosen for the study. Twelve practices from each state were randomly selected from the American Orthopedic Society for Sports Medicine directory, resulting in a sample size of 96 independent sports medicine offices. Each office was called twice to request an appointment for a fictitious 16-year-old first-time shoulder dislocator with either in-state Medicaid insurance or Blue Cross Blue Shield (BCBS) private insurance. A total of 91 physician offices in 8 states were contacted by telephone. An appointment was obtained at 36 (39.6%) offices when calling with Medicaid and at 74 (81.3%) offices when calling with BCBS (P < .001). Thirty-five (38.5%) offices were able to make appointments for both types of insurance, 39 (42.9%) for only BCBS, 1 (1.1%) for only Medicaid, and 16 (17.5%) for neither. For Medicaid patients, an appointment was booked in 13 (27.7%) clinics from Medicaid expanded states and in 23 (52.3%) clinics from unexpanded states (P = .016). For a first-time shoulder dislocator, access to care is more difficult with Medicaid insurance compared with private insurance. Within Medicaid insurance, access to care is more difficult in Medicaid expanded states compared with unexpanded states. Medicaid patients in unexpanded states are twice as likely as those in expanded states to obtain an appointment.

Nationwide trends in management of proximal humeral fractures: an analysis of 77,966 cases from 2008 to 2017

20-08-2019 – Andrew S. McLean, Nathan Price, Stephen Graves, Alesha Hatton, Fraser J. Taylor

Journal Article

There is no consensus as to the treatment of proximal humeral fractures (PHFs), particularly in elderly patients. There is increasing evidence that nonoperative management may have similar functional outcomes to operative management, which is potentially conflicting with increasingly improved surgical techniques and implants. The aim of this study was to investigate the changes in the incidence and management of PHFs across Australia over a 10-year period. We retrospectively reviewed all hospitalizations of patients with PHFs from 2 Australian national health care databases from 2008 to 2017. We recorded the incidence of PHFs and annual utilization rates of commonly used treatment options including nonoperative management, hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA), and open reduction-internal fixation (ORIF). The incidence of PHFs increased from 26.8 per 100,000 person-years in 2008 to 45.7 per 100,000 person-years in 2017. There was a decrease in operative management from 2008 to 2017, with 32.5% and 22.8% of all PHFs treated operatively in 2008 and 2017, respectively (P = .001). ORIF use decreased significantly from 76.6% to 72.6% (P = .004). RTSA use increased significantly from 4.1% to 24.5% (P < .001). HA use decreased significantly from 19.3% to 3% (P < .001). Whereas the incidence of PHFs increased, the operative management of PHFs decreased significantly from 2008 to 2017, particularly in patients aged 65 years or older. This decrease in operative management was in part due to a significant decrease in ORIF and HA use in patients aged 65 years or older. There was a significant increase in RTSA use.

Core set of unfavorable events of shoulder arthroplasty: an international Delphi consensus process

23-09-2019 – Laurent Audigé, Hans-Kaspar Schwyzer, Ville Äärimaa, Tjarco D. Alta, Marcus Vinicius Amaral, Alison Armstrong, Arthur van Noort, Steve Bale, Shaul Beyth, Andreas Bischof, Desmond J. Bokor, Mario Borroni, Stig Brorson, Peter Brownson, Stefan Buchmann, Eduard Buess, Benjamin Cass, Cormac Kelly, Vincenzo De Cupis, Philippe Debeer

Journal Article

Shoulder arthroplasty (SA) complications require standardization of definitions and are not limited to events leading to revision operations. We aimed to define an international consensus core set of clinically relevant unfavorable events of SA to be documented in clinical routine practice and studies. A Delphi exercise was implemented with an international panel of experienced shoulder surgeons selected by nomination through professional societies. On the basis of a systematic review of terms and definitions and previous experience in establishing an arthroscopic rotator cuff repair core set, an organized list of SA events was developed and reviewed by panel members. After each survey, all comments and suggestions were considered to revise the proposed core set including local event groups, along with definitions, specifications, and timing of occurrence. Consensus was reached with at least two-thirds agreement. Two online surveys were required to reach consensus within a panel involving 96 surgeons. Between 88% and 100% agreement was achieved separately for local event groups including 3 intraoperative (device, osteochondral, and soft tissue) and 9 postoperative event groups. Experts agreed on a documentation period that ranged from 3 to 24 months after SA for 4 event groups (peripheral neurologic, vascular, surgical-site infection, and superficial soft tissue) and that was lifelong until implant revision for other groups (device, osteochondral, shoulder instability, pain, late hematogenous infection, and deep soft tissue). A structured core set of local unfavorable events of SA was developed by international consensus to support the standardization of SA safety reporting. Clinical application and scientific evaluation are needed.

The use of biologics for the elbow: a critical analysis review

06-10-2019 – Jason L. Dragoo, Molly C. Meadows

Journal Article, Review

There is significant interest in biologic treatment options to improve the healing environment and more rapidly decrease symptoms in many conditions around the elbow. Despite fairly widespread use of biologic agents such as platelet-rich plasma (PRP) in the elbow, there is a lack of clear evidence in the literature to support its use. The potential impact of these biologic agents must be evaluated with evidence from high-quality studies, particularly considering the high financial burden these treatments often impose on patients. The aim of this review is to provide an evidence-based summary of the biologic augmentation options available for use by the physician treating painful conditions of the elbow and to identify areas where further research is warranted.

The role of biologic agents in the management of common shoulder pathologies: current state and future directions

06-10-2019 – James B. Carr, Scott A. Rodeo

Journal Article, Review

The field of orthopedic surgery has seen a rapid increase in the use of various biologic agents for the treatment of common musculoskeletal injuries. Most biologic agents attempt to harness or mimic naturally occurring growth factors, cytokines, and anti-inflammatory mediators to improve tissue healing and recovery. The most commonly used biologic agents are platelet-rich plasma and cells derived from bone marrow aspirate and adipose tissue. These agents have become increasingly popular despite a relative dearth of clinical data to support their use. Much confusion exists among patients and physicians in determining the role of these agents in treating common shoulder pathologies, such as glenohumeral osteoarthritis, rotator cuff tears, and tendinopathy. This article reviews the basic science and clinical evidence for the most commonly used biologic agents in the management of common shoulder pathology.

The New York Times, May 13, 2019: “Stem Cell Treatments Flourish With Little Evidence That They Work”

06-10-2019 – Jason L. Dragoo, Scott A. Rodeo


Supination torque following single- versus double-incision repair of acute distal biceps tendon ruptures

18-10-2019 – David J. Stockton, Gabriel Tobias, Jeffrey M. Pike, Parham Daneshvar, Thomas J. Goetz

Journal Article

Compared with single-incision (SI) distal biceps repair, double-incision (DI) repair has been described as permitting a more anatomic repair. We hypothesized that DI repair would result in greater terminal supination torque compared with SI repair for acute distal biceps ruptures. Patients were included if they sustained an isolated, acute distal biceps rupture repaired between January 2012 and December 2017. Isometric forearm supination torque in 4 positions was measured using a validated uniaxial torque-testing device. Testing took place at least 12 months from surgery. The primary outcome was supination torque in the 60° supinated position. Secondary outcomes included supination torque in other forearm positions and functional outcome scores. The study included 37 patients: 15 underwent repair with the DI technique and 22 with the SI technique. The mean age was 47.3 years, the median follow-up time was 28.1 months, and demographic data were similar between cohorts. Mean supination torque, relative to the unaffected side, was 61% (95% confidence interval, 45%-77%) for DI repair vs. 80% (95% confidence interval, 69%-92%) for SI repair in the 60° supinated position (P = .036). In a multivariable linear regression model controlling for arm dominance, age, follow-up time, and workers’ compensation status; SI repair was associated with greater mean supination torque than DI repair by 20% (P = .015). Contrary to our hypothesis, we found a 20% mean improvement in terminal supination torque for acute distal biceps ruptures repaired with the SI technique compared with the DI technique. This finding may have clinical significance for the more discerning, high-demand patient.

Next-generation sequencing for diagnosis of infection: is more sensitive really better?

18-10-2019 – Allison J. Rao, Ian S. MacLean, Amanda J. Naylor, Grant E. Garrigues, Nikhil N. Verma, Gregory P. Nicholson

Journal Article

The utility of next-generation sequencing (NGS) in differentiating between active infection and contaminant or baseline flora remains unclear. The purpose of this study is to compare NGS with culture-based methods in primary shoulder arthroplasty. A prospective series of primary shoulder arthroplasty patients with no history of infection or antibiotic use within 60 days of surgery was enrolled. All patients received standard perioperative antibiotics. After skin incision, a 10 × 3-mm sample of the medial skin edge was excised. A 2 × 2-cm synovial tissue biopsy was taken from the rotator interval after subscapularis takedown. Each sample set was halved and sent for NGS and standard cultures. Samples from 25 patients were analyzed. Standard aerobic/anaerobic cultures were positive in 10 skin samples (40%, 95% confidence interval [CI] 20%-60%) and 3 deep tissue samples (12%, 90% CI 1%-23%]). NGS detected ≥1 bacterial species in 17 of the skin samples (68%, 95% CI 49%-87%) and 7 deep tissue samples (28%, 95% CI 9%-47%). There was a significant difference (P < .03) in the mean number of bacterial species detected with NGS between the positive standard culture (1.6 species) and the negative standard culture groups (5.7 species). NGS identified bacteria at higher rates in skin and deep tissue samples than standard culture did in native, uninfected patients undergoing primary procedures. Further research is needed to determine which NGS results are clinically relevant and which are false positives before NGS can be reliably used in orthopedic cases.

Predictors of patient satisfaction after reverse shoulder arthroplasty

18-10-2019 – Ryan C. Rauck, Joseph J. Ruzbarsky, Ishaan Swarup, Jordan Gruskay, Joshua S. Dines, Russell F. Warren, David M. Dines, Lawrence V. Gulotta

Journal Article

The aims of this study were to determine patient satisfaction and to identify predictors of satisfaction after reverse shoulder arthroplasty (RSA). We hypothesized that the majority of patients would be satisfied after RSA and that patients with worse preoperative mental and physical health would be less satisfied. Satisfaction was assessed 2 years after primary RSA with domains for pain, work, activities, quality of life, and overall satisfaction. Preoperative and postoperative patient-reported factors were measured using the American Shoulder and Elbow Surgeons (ASES) shoulder score, Shoulder Activity Scale score, Short Form 12 (SF-12) mental and physical component summary scores, and visual analog scale (VAS) pain, fatigue, and general health scores. Pearson correlations were used to determine the relationship between patient-reported factors and satisfaction. Multivariate regression was performed to control for potential confounding variables. A total of 161 patients were evaluated at 2 years postoperatively. Patients were “very satisfied” in an average of 3.3 of the 5 domains. Improvements in ASES, Shoulder Activity Scale, VAS pain, and SF-12 physical component summary scores were associated with higher satisfaction, with correlation coefficients ranging from 0.27 to 0.49. On multivariate analysis, patients with higher preoperative ASES scores were less satisfied after surgery (P = .005). In addition, patients with worse VAS fatigue (P = .011) and SF-12 mental (P = .034) and physical (0.011) component summary scores preoperatively had lower satisfaction. Improvements in pain and outcome scores are associated with increased satisfaction. Patients with higher shoulder function, worse physical health, and worse mental health prior to surgery are more likely to have lower satisfaction after RSA.

Early radiographic failure of reverse total shoulder arthroplasty with structural bone graft for glenoid bone loss

16-10-2019 – Jason C. Ho, Ocean Thakar, Wayne W. Chan, Thema Nicholson, Gerald R. Williams, Surena Namdari

Journal Article

Structural glenoid bone grafting in reverse total shoulder arthroplasty (RSA) has previously been reported to have good functional outcomes and low complication rates. We have observed different complication rates and hypothesized that baseplate fixation and severity of deformity may be predictors of early failure. We retrospectively identified 44 patients who underwent RSA with structural bone grafting for glenoid bone defects. All patients had preoperative and postoperative (Grashey and axillary) radiographs at a minimum of 1 year after surgery and within 3 months of surgery for evaluation of implant and graft positioning. Clinical data and outcome scores were collected at the same intervals. There were 61% females and 39% males, with an average age of 74 ± 8 years at the time of surgery. The median final radiographic follow-up was 20 months, with 37 primary RSA and 7 revision RSA. Graft resorption was found in 11 of 44 patients (25%), and radiographic failure was found in 11 of 44 patients (25%) at a median of 8 months (range 3-51 months). Forward elevation, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores all significantly improved postoperatively (P < .0001). Radiographic baseplate failure was associated with graft resorption (P = .002), more retroversion correction (P = .02), and worse SANE scores at final follow-up (P = .01). RSA with structural bone graft improved range of motion and function, but there was a larger than previously reported baseplate loosening rate. This early radiographic loosening appeared to be associated with graft resorption, retroversion correction, and worse outcome scores.

The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis

14-10-2019 – Vani J. Sabesan, Diego J.L. Lima, Yang Yang, Matthew C. Stankard, Mauricio Drummond, William W. Liou

Journal Article

The lack of greater tuberosity (GT) healing in proximal humerus fractures has been negatively correlated with outcomes for hemiarthroplasty; however, there is still debate regarding the effects of GT healing in reverse shoulder arthroplasty (RSA). Our goal was to examine the effects of GT healing using a kinematic finite element analysis (FEA) model. Computer-aided design models of a medialized glenoid with a lateralized humerus (MGLH) RSA design were uploaded into an FEA shoulder model in 2 different configurations: healed greater tuberosity (HGT) and nonunion greater tuberosity (NGT). Deltoid muscle forces and joint reaction forces (JRFs) on the shoulder were calculated during abduction (ABD), forward flexion (FF), and external rotation (ER). Force magnitude of the anterior, middle, and posterior deltoid muscle as well as JRFs modeled in both GT scenarios were similar for ABD (muscle forces P = .91, P = .75, P = .71, respectively; and JRF P = .93) and for FF (muscle forces P = .89, P = .83, P = .99, respectively; and JRF P = .90). For ER, the force magnitude between 2 GT settings showed statistically significant differences (HGT: 9.51 N vs. NGT: 6.13 N) (P < .001). Likewise, during ER, JRFs were different, and the NGT group showed a steep drop in JRF after 10° of ER (HGT: 28.4 N vs. NGT: 18.38 N) (P < .001). GT healing does not seem to impact RSA biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. Overall orthopedic surgeons can expect good results for patients after RSA even with poor GT healing.

Motion quality in rotator cuff tear using an inertial measurement unit: new parameters for dynamic motion assessment

12-10-2019 – Jae-Man Kwak, Tae-Hyun Ha, Yucheng Sun, Erica Kholinne, Kyoung-Hwan Koh, In-Ho Jeon

Journal Article

This study aimed to (1) figure out the difference in motion smoothness between a nonpathologic shoulder and the other with a rotator cuff tear by measuring the angular velocity using an inertial measurement unit (IMU) sensor and (2) propose the parameters to describe the difference because there is no literature on this topic. We enrolled patients with rotator cuff disease diagnosed by magnetic resonance imaging. The intact shoulder of participants was compared with the shoulder with rotator cuff tear by using IMU on the basis of the parameters that establish motion smoothness: the number of peaks, the peak velocity-to-mean velocity ratio (PV/MV), and the number of sign reversals. In addition, subgroup analysis was performed with respect to tear size (small to medium vs. large to massive). In addition, correlations with the American Shoulder and Elbow Surgeons score and symptom duration (months) were evaluated. Among 24 patients (15 males, 9 females), all 3 parameters for the motion quality of patients with a rotator cuff tear exhibited significant difference. The parameters showed a significant difference between the small to medium tear group and the large to massive tear group. A negative correlation was found between symptom duration and parameters of motion quality, except for PV/MV. Motion quality assessment using IMU showed a marked difference in the shoulder with a rotator cuff tear compared with the intact shoulder. Hence, IMU-based parameters for dynamic motion quality could be considered as an option for assessing the function of the shoulder.

Biomechanical analysis of anterior capsule reconstruction and latissimus dorsi transfer for irreparable subscapularis tears

09-10-2019 – Reza Omid, Michael A. Stone, Charles C. Lin, Nilay A. Patel, Yasuo Itami, Michelle H. McGarry, Thay Q. Lee

Journal Article

Anterior capsule reconstruction (ACR) and latissimus dorsi transfers (LTs) have been proposed as solutions for irreparable subscapularis tears. The purpose of this study was to biomechanically assess the effects of ACR and LT separately and together for treatment of irreparable subscapularis tears. Eight cadaveric shoulders underwent 5 testing conditions: (1) intact, (2) irreparable subscapularis tear, (3) ACR, (4) ACR+LT, and (5) LT alone. Anteroinferior translation loads of 20, 30, and 40 N were applied. Range of motion and magnitudes of glenohumeral anterior and inferior translation at 0°, 30°, and 60° of abduction and at 30° and 60° of external rotation were measured for each testing condition. At 30° of abduction and 60° of external rotation, ACR and ACR+LT restored anterior and inferior translation to intact (P > .702) for 30 and 40 N of anteroinferiorly directed force. LT alone did not restore anteroinferior stability at 30 N of distraction force at 30° of glenohumeral abduction and 60° of external rotation (P < .001). However, ACR and ACR+LT led to significant decreases in total range of motion compared to intact at 0° and 30° of abduction (P < .007). ACR with dermal allograft was able to restore anteroinferior stability in the setting of irreparable subscapularis tears but resulted in decreased total range of motion. LT alone was less effective than ACR in restoring glenohumeral stability. The addition of LT as a dynamic restraint did not increase the efficacy of ACR.

Three anchor concepts for rotator cuff repair in standardized physiological and osteoporotic bone: a biomechanical study

09-10-2019 – Claudio Rosso, Timo Weber, Alain Dietschy, Michael de Wild, Sebastian Müller

Journal Article

Previous biomechanical studies used single-pull destructive tests in line with the anchor and are limited by a great variability of bone density of cadaver samples. To overcome these limitations, a more physiological test setting was provided using titanium, bioresorbable, and all-suture anchors. In this controlled laboratory study, 3 anchor constructs were divided into 2 groups: physiological and osteoporotic. Sixty standardized artificial bone specimens (=10 for each anchor in each group) were used for biomechanical testing. The anchors were inserted at a 45° angle as during surgery. Cyclic loading for 1000 cycles followed by ultimate load-to-failure (ULTF) testing was performed. Elongation, ultimate load at failure, and the mode of failure were noted. In the physiological group, the ULTF for the all-suture anchor (mean [standard deviation], 632.9 [96.8 N]) was found to be significantly higher than for the other anchors (titanium, 497.1 [50.5] N, and bioresorbable, 322.4 [3.1 N], P < .0001). The titanium anchor showed a significantly higher ULTF than the bioresorbable anchor (P < .0001). In the osteoporotic group, the all-suture anchor again showed a higher ULTF compared to the bioresorbable anchor (500.9 [50.6] N vs. 315.1 [11.3] N, P < .0001). In the osteoporotic group, cyclic loading revealed a higher elongation after 1000 loading cycles for the bioresorbable (0.40 [0.12] mm) compared to the titanium (0.22 [0.11] mm; P = .01) as well as the all-suture anchor (0.19 [0.15] mm, P = .003). Regarding ULTF, the all-suture anchor outperformed the other anchors in physiological bone, but in osteoporotic bone, significance was reached only compared to the bioresorbable anchor. Although cyclic loading revealed significant differences, these might not be clinically relevant.

Clinical and structural outcome 20 years after repair of massive rotator cuff tears

09-10-2019 – Philippe Collin, Michael Betz, Anthony Herve, Gilles Walch, Pierre Mansat, Luc Favard, Michel Colmar, Jean François Kempf, Hervé Thomazeau, Christian Gerber

Journal Article

Short- and mid-term outcomes after massive cuff tear repair are well reported, but there is no documentation of the clinical and structural outcomes at 20 years of follow-up. The hypothesis of the present study was that at 20 years, deterioration of the shoulder would have occurred and led to a substantial number of reoperations. The authors retrospectively recalled all 127 patients operated for massive rotator cuff tears in 1994 at 6 different centers. At the 20-year follow-up, 26 patients died and 35 were lost to follow-up. Thirteen (10.2%) had been reoperated. This left 53 patients for personal clinical assessment. Forty-nine consented to standardized radiographic evaluation for assessment of osteoarthritis, 36 patients underwent magnetic resonance imaging, allowing assessment of tendon healing, atrophy, and fatty infiltration (FI) of the cuff muscles. The final Constant-Murley score (CS) was 68 ± 17.7 (range, 8-91) vs. 44 ± 15.3 (range, 13-74) preoperatively (P < .05). The final Subjective Shoulder Value (SSV) was 73% ± 23% (range, 0-100). Retears (Sugaya IV and V) were found in 17 cases (47%). Nine patients (17%) had cuff tear arthropathy (Hamada stage 4). The CS and SSV for the shoulders with FI stages III or IV were significantly inferior (53 ± 19 points and 65% ± 14% respectively) than for those with FI stages 0-II (respectively, 71.6 ± 6 points and 73% ± 4%) (P < .05). Twenty years after surgical repair of massive rotator cuff tears, the functional scores remain satisfactory, and the rate of revision is low.

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results

09-10-2019 – Lukas Ernstbrunner, Stefan Rahm, Aline Suter, Mohamed A. Imam, Sabrina Catanzaro, Florian Grubhofer, Christian Gerber

Journal Article

Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years? Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally. At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA. Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.

Revision of failed shoulder arthroplasty: epidemiology, etiology, and surgical options

09-10-2019 – Marc-Olivier Gauci, Maxime Cavalier, Jean-François Gonzalez, Nicolas Holzer, Toby Baring, Gilles Walch, Pascal Boileau

Journal Article

Our aim was to analyze the epidemiology, etiologies, and revision options for failed shoulder arthroplasty from 2 tertiary centers. From 1993 to 2013, 542 failed arthroplasties were revised in 540 patients (65% women): 224 hemiarthroplasties (HAs, 41%), 237 anatomic total shoulder arthroplasties (TSAs, 44%) and 81 reverse total arthroplasties (RSAs, 15%). Data about patients, pathology, and reintervention procedures, as well as intraoperative data, were analyzed from our 2 local registries that prospectively captured all the revision procedures. Patients had an average follow-up period of 8.7 years. The revision rate was 12.7% for HAs, 6.7% for TSAs, and 3.9% for RSAs. HAs were revised earlier (33 ± 40 months) than RSAs (47 ± 150 months) and TSAs (69 ± 61 months). Glenoid failure was a major cause of reintervention: erosion in HAs (29%) or loosening in TSAs (37%) and RSAs (24%). Instability was another major cause of reintervention: 32% in RSAs, 20% in TSAs, and 13% in HAs. Humeral implant loosening led to revision in 10% of RSAs, 6% of HAs, and 6% of TSAs. Multiple reinterventions were required in 21% of patients, mainly for instability (26%) and/or infection (25%). The final implant was an RSA in 48%, especially when associated with cuff insufficiency, instability, and/or bone loss. Final reimplantation was possible in 90% of cases, with the remaining 10% treated with a resection or spacer. Glenoid failure and instability are the most common causes of revision. Soft-tissue insufficiency and/or infection results in multiple revisions. Surgeons must recognize all complications so that they can be addressed at the first revision operation and avoid further reinterventions. RSA was the most common final revision implant.

Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy

13-05-2019 – William R. Aibinder, Ryan T. Bicknell, Stefan Bartsch, Markus Scheibel, George S. Athwal

Journal Article

It is unknown whether subscapularis management technique has an influence on the outcomes and complications of stemless total shoulder arthroplasty. The purpose of this study, therefore, was to compare outcomes and complications between subscapularis tenotomy, peel, and lesser tuberosity osteotomy used during stemless shoulder arthroplasty. We reviewed 188 stemless anatomic total shoulder arthroplasties and compared clinical and functional outcomes between those performed through a subscapularis tenotomy (n = 68), subscapularis peel (n = 65), or lesser tuberosity osteotomy (n = 55). Patients were followed up clinically and radiographically at 6 months, 1 year, and 2 years postoperatively. At 2 years postoperatively, no statistically significant differences in visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, or patient-reported instability (P ≥ .19) were found between groups. Active external rotation was greater in the peel group (P = .006) than in the tenotomy group but was not different compared with the lesser tuberosity osteotomy group (P = .07). No statistically significant difference in clinical subscapularis failures was noted between groups (P = .11); however, 2 patients in the peel group sustained a subscapularis failure requiring reoperation. The results of this multicenter comparative analysis show that all 3 subscapularis management techniques are effective and safe in the short term when used with stemless anatomic total shoulder arthroplasty.

Preoperative IDEAL (Iterative Decomposition of Echoes of Asymmetrical Length) magnetic resonance imaging rotator cuff muscle fat fractions are associated with rotator cuff repair outcomes

03-08-2019 – Drew A. Lansdown, Cyrus Morrison, Musa B. Zaid, Rina Patel, Alan L. Zhang, Christina R. Allen, Brian T. Feeley, C. Benjamin Ma

Journal Article

IDEAL (Iterative Decomposition of Echoes of Asymmetrical Length) imaging is a magnetic resonance imaging sequence that precisely measures rotator cuff muscle fatty infiltration. The influence of lower levels of fatty infiltration on outcomes after rotator cuff repair remains unclear. We hypothesized that increased preoperative fat fractions would be associated with inferior clinical outcomes after rotator cuff repair. We retrospectively identified patients who underwent arthroscopic rotator cuff repair with preoperative IDEAL imaging. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity computer adaptive survey at a minimum of 2 years after repair. Muscle segmentation was performed on 4 consecutive slices. Correlations between intramuscular fat fractions and PROMIS scores were determined. Patients were grouped by PROMIS scores of 50 or greater and scores lower than 50 for comparison of fat fractions. Multivariate linear regression was performed to model PROMIS scores as a function of demographic characteristics, tear size, and fat fractions. Significance was defined as P < .05. Eighty patients were included (mean follow-up, 42.5 ± 10.7 months). Postoperative PROMIS scores were significantly inversely correlated with the infraspinatus (ρ = -0.25, P = .02) and subscapularis (ρ = -0.29, P = .009) fat fractions. The infraspinatus (7.2% ± 4.9% vs. 5.2% ± 3.0%, P = .046) and subscapularis (10.4% ± 5.1% vs. 8.2% ± 5.0%, P = .001) fat fractions were significantly higher for patients with low PROMIS scores vs. those with PROMIS scores of 50 or greater. In multivariate modeling, the infraspinatus fat fraction (β = -0.68, P = .029) was the only significant independent predictor of postoperative PROMIS score. Intramuscular fat as determined by quantitative magnetic resonance imaging is an important factor in postoperative outcomes even in patients with lower levels of preoperative fatty infiltration.

Opioid use following shoulder stabilization surgery: risk factors for prolonged use

12-08-2019 – Zain M. Khazi, Yining Lu, Alan G. Shamrock, Kyle R. Duchman, Robert W. Westermann, Brian R. Wolf

Journal Article

The purpose of this study was to determine the rate of opioid use before and after shoulder stabilization surgery for instability due to recurrent dislocation and assess patient factors associated with prolonged opioid use postoperatively. Patients undergoing primary shoulder stabilization procedures for shoulder instability due to recurrent dislocation were accessed from the Humana administrative claims database. Patients were categorized as those who filled 1 or more opioid prescriptions within 1 month, those who filled opioid prescriptions between 1 and 3 months, and those who never filled opioid prescriptions before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each group. Multiple binomial logistic regression analysis was used to identify factors associated with opioid use at 3 months and 1 year after surgery. Overall, 4802 patients (45.9% opioid naive) underwent shoulder stabilization surgery for shoulder instability during the study period. Rates of opioid use significantly declined after the first postoperative month; however, at 1 year, the rate of opioid use was significantly greater in patients who filled opioid prescriptions preoperatively (13.4% vs. 1.9%, P < .0001). Filling opioid prescriptions 1 to 3 months prior to surgery was the strongest risk factor for opioid use at 1 year after surgery. Patients who were prescribed opioids 1 to 3 months before surgery had the highest risk of prolonged opioid use following surgery. Obesity, tobacco use, and a preoperative diagnosis of fibromyalgia were independently associated with prolonged opioid use following surgery.

Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes

22-09-2019 – Paolo Avanzi, Luca dei Giudici, Antonio Capone, Gaia Cardoni, Gianluigi Lunardi, Giovanni Foti, Claudio Zorzi

Journal Article

To evaluate the anatomic integrity of rotator cuff repair performed by medialized single row and augmented by a porcine dermal patch, in comparison with a nonaugmented group. We conducted a single-center, prospective, double-blinded, randomized controlled trial. The sample size was predefined, and patients were divided into a study group and a control group, assessed preoperatively and at 1, 3, 6, 12, and 24 months. The Euro
Qol-visual analog scale; Constant-Murley questionnaire; Disabilities of the Arm, Shoulder and Hand Score; and Simple Shoulder Test were administered. The humeral-acromial distance was calculated on radiographs. Tendon thickness, tear extension, and tendon signal intensity were all measured on magnetic resonance images (MRIs) along with an evaluation of footprint extension and a classification into one of 4 healing grades-healed, thinned, partially healed, not healed. The study population consisted of 92 patients who were equally randomized into 2 homogenous groups. Sixty-nine patients completed the 24-month follow-up. The study group showed a healing rate of 97.6% compared with 59.5% for the standard repair group. The study group showed better results in terms of repaired tendon thickness and footprint coverage, with a P value < .05, although the tendon density was comparable. The study group showed better strength recovery and functionality with the outcome scores submitted. During the entire study, only 2 patients reported complications, calling for a biopsy during revision surgery. Rotator cuff repairs augmented with a porcine dermal patch resulted in excellent clinical outcomes with a higher healing rate and close-to-normal MRI findings. The technique is safe and effective; in addition, it is reproducible and allows for better outcomes compared with those of standard medialized single-row repairs.

Fluid retention after shoulder arthroscopy: gravity flow vs. automated pump—a prospective randomized study

12-08-2019 – Bilgehan Çatal, İbrahim Azboy

Journal Article

Soft tissue fluid retention due to irrigation is relatively common after shoulder arthroscopy. The objective of this study was to compare fluid retention of 2 irrigation systems of shoulder arthroscopy: gravity flow irrigation and automated pump. Patients undergoing shoulder arthroscopy were enrolled prospectively and randomized into 2 groups using gravity flow system (GFS) or automated pump system (APS) for irrigation. Net weight gain was the primary outcome measurement to determine periarticular fluid retention. Change in deltoid diameter and postoperative pain were also compared. Forty-two patients were included in the study. There were no statistically significant differences between the GFS and APS groups regarding demographics, surgical procedures, duration of surgery, or the amount of irrigation fluid used. The APS group had greater weight gain per hour (1.46 ± 0.36 kg/h vs. 1.1 ± 0.38 kg/h) than the GFS group. A strong correlation was found between the amount of fluid used and the weight gain in both the GFS and APS groups. But a strong correlation between duration of surgery and weight gain was found in the APS group only. The APS group also had a greater mean deltoid diameter increase (3.33 ± 1.56 cm vs. 2.1 ± 1.44 cm) and a higher postoperative first-hour visual analog pain scale score (5.81 ± 2 vs. 3.62 ± 1.6). APS causes more fluid retention than GFS in shoulder arthroscopy when used for equal duration in similar procedures. Use of APS, prolongation of surgery, and increased amounts of irrigation fluid increase weight gain as a result of fluid retention.

Glenohumeral translation during active external rotation with the shoulder abducted in casesxa0with glenohumeral instability: a 4-dimensionalxa0computed tomography analysis

18-06-2019 – Noboru Matsumura, Satoshi Oki, Naoto Fukasawa, Morio Matsumoto, Masaya Nakamura, Takeo Nagura, Yoshitake Yamada, Masahiro Jinzaki

Journal Article

Although glenohumeral instability is common, the mechanism of instability remains unclear. The purpose of this study was to quantitatively evaluate humeral head translation during active external rotation with abduction in patients with glenohumeral instability by use of 4-dimensional computed tomography scans. Ten patients with unilateral glenohumeral instability with a positive fulcrum test were prospectively included in this study. Sequential computed tomography of bilateral shoulders during active external rotation at 90° of shoulder abduction was performed for 6 seconds at 5 frames per second. The 3-dimensional positions of the humeral head center in the anteroposterior, superoinferior, and mediolateral directions were calculated at 0°, 20°, 40°, 60°, and maximum shoulder abduction-external rotation from the starting position. Translation of the humeral head center from the starting position was evaluated using Dunnett multiple-comparison tests, and the differences between the affected and intact shoulders were assessed using Wilcoxon signed rank tests. The humeral head center translated posteriorly, inferiorly, and medially during glenohumeral external rotation with the shoulder in the abducted position on the intact side. However, the affected humeral head showed significantly less posterior translation (P = .028), greater inferior translation (P = .047), and less medial translation (P = .037) than the contralateral side. This study indicated that dysfunction of the anterior band of the inferior glenohumeral ligament causes decreased posterior, increased inferior, and decreased medial translation of the humeral head during active shoulder abduction-external rotation.

Rotator cuff tendon tissue cut-through comparison between 2 high–tensile strength sutures

16-05-2019 – Brett D. Owens, Joseph Algeri, Vivian Liang, Steven DeFroda

Journal Article

High-tensile strength sutures are known to cut through tendon tissue when used for rotator cuff and other tendon repairs, resulting in mechanical failure. The purpose of this study was to test a new suture and compare it with an established suture in a controlled laboratory setting. Two sutures, Dynacord and Fiber
Wire, both USP size No. 2, were passed through fresh infraspinatus tendons from 7 matched pairs of ovine shoulders (14 shoulders). Samples underwent cyclic testing for 1000 cycles, and the amount of cheese-wire tissue damage (tendon cut-through) was recorded. A clinical failure was defined as greater than 5 mm of tissue cut-through. The mean amount of tendon cut-through was 3.72 ± 1.14 mm in the Fiber
Wire specimens and 2.69 ± 1.02 mm in the Dynacord group. The difference was statistically significant (P = .012). In the matched-pair analysis, more tendon cut-through was noted with Fiber
Wire in 13 specimens whereas a greater amount was found in only 1 Dynacord specimen. The Fiber
Wire specimens showed 2 instances of tissue tendon cut-through exceeding 5 mm, defined as a clinical failure. In this cadaveric ovine rotator cuff tendon model, we found less tendon cut-through from Dynacord suture compared with Fiber
Wire. In addition, 2 of the Fiber
Wire specimens showed complete tendon cut-through. Future studies focusing on patient-reported outcomes and healing rates with different types of suture materials are needed.

Bone adaptation impact of stemless shoulder implants: a computational analysis

01-07-2019 – Manuel Comenda, Carlos Quental, João Folgado, Marco Sarmento, Jacinto Monteiro

Journal Article

Despite stemless implants showing promising functional and radiologic clinical outcomes, concerning signs of complications, such as bone resorption, have been reported. The aim of this study was to investigate the influence of 5 stemless designs on the bone adaptation process of the humerus. Three-dimensional finite element models of shoulder arthroplasties were developed considering stemless designs based on the Eclipse, Global Icon, SMR, Simpliciti, and Sidus stemless systems. For the designs not possessing a collar that covers the entire resected surface of the humerus, conditions of contact and no contact were simulated between the humeral head components and the bone surface. By use of a bone remodeling model, computational simulations were performed considering 6 load cases of standard shoulder movements. The bone adaptation process was evaluated by comparing differences in bone density between the implanted models and the intact model of the humerus. Overall, the design of the stemless implants had a relevant impact on the bone adaptation process of the humerus. The Eclipse-based design caused the largest bone mass loss, whereas the SMR-based design caused the least. When contact was simulated between the humeral head components of the SMR-, Simpliciti-, and Sidus-based designs and the resected bone surface, bone resorption increased. Considering only the bone adaptation process, the results suggest that the SMR-based implant presents the best performance and that contact between the humeral head component and the resected bone surface should be avoided. However, because other factors must be considered, further investigation is necessary to allow definite recommendations.

Three-dimensional clavicle displacement analysis and its effect on scapular position in acute clavicle midshaft fracture

06-07-2019 – Jung-Han Kim, Heui-Chul Gwak, Chang-Wan Kim, Chang-Rack Lee, Young-Jun Kim, Hyeong-Won Seo

Journal Article

The purpose of this study was to measure the distance of the clavicle in 3 dimensions (3D) and each direction (anterior to posterior, medial to lateral, and superior to inferior) and to analyze the correlation of the angular orientation of the scapula according to each directional distance of the clavicle. Sixty-seven patients with Robinson 2B1 and 2B2 clavicle midshaft fracture (46.0 ± 17.4 years, men = 50, women = 17) were selected as final subjects. Patients’ computed tomography was reconstructed using an image processing program (3D Slicer 4.3 software). Anteroposterior (AP) distance, medial-to-lateral distance, superior-to-inferior distance, and 3D distance of both clavicles were measured. The plane connecting the 3 points (superior pole, inferior pole, and center of glenoid) of the scapula was used to calculate differences in the angular orientation between both scapulae. Among each directional distance of the clavicle, only the AP distance showed negative correlation with scapular angular orientation with anterior tilting, internal rotation, and upward rotation of the scapula (Pearson’s correlation coefficient: -0.68, -0.24, and -0.28; P < .001, P = .048, and P = .021). The shortening of the AP distance of the clavicle was related to the angular orientation of the scapula in acute clavicle fracture. AP shortening should be considered when determining the treatment of clavicle fracture.

Correlation of multiple patient-reported outcome measures across follow-up in patients undergoing primary shoulder arthroplasty

13-05-2019 – Rowan J. Michael, Brendan A. Williams, Martin D. Laguerre, Aimee M. Struk, Bradley S. Schoch, Thomas W. Wright, Kevin W. Farmer, Terrie Vasilopoulos, Joseph J. King

Journal Article

Multiple validated outcome scores are used to assess patients undergoing shoulder arthroplasty. The purpose of this study was to determine whether a correlation exists between 3 commonly used patient-reported outcome (PRO) measures in this population: Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) Assessment Form, and Simple Shoulder Test (SST). We performed a retrospective review of a shoulder arthroplasty database that routinely collects SPADI, ASES, and SST scores at each visit prospectively. Patients undergoing primary shoulder arthroplasty were identified. Assessments of correlation coefficients (Pearson correlation coefficient for ASES and SPADI scores and Spearman correlation coefficient for SST score) between each combination of PROs were performed overall and at each time point (preoperatively and 3, 6, 12, and 24 months postoperatively) to determine the level of association between PROs. In total, 848 shoulder arthroplasty procedures were performed in 754 patients with 2796 unique clinical encounters. Preoperative correlations among PROs were moderate to strong (range, 0.66-0.77) but had the lowest correlation among all comparisons. Postoperative correlations were strong for all PRO comparisons (range, 0.73-0.94). Postoperative PRO correlations continued to strengthen over longer follow-up, with all values exceeding 0.78 at 2 years postoperatively. Conversion equations between PROs were calculated based on these highly correlated data. After primary shoulder arthroplasty, there exists a high degree of correlation among all 3 studied PROs. Correlations were stronger postoperatively and improved with longer follow-up. Surgeons may use this information to minimize the number of questionnaires patients answer at each follow-up time point, and the conversion equations can be used for study comparison in meta-analyses.

Does strength deficit correlate with shoulder function in patients with rotator cuff tears? Characteristics of massive tears

08-07-2019 – Joo Han Oh, Jong Pil Yoon, Dong Hyun Kim, Seok Won Chung, Joon Yub Kim, Hyun-Joo Lee, Seo Il, Kyeong Hyeon Park, Hoseok Lee

Journal Article

The correlation between shoulder strength deficits and function in rotator cuff tears remains uncertain. This study aimed to determine the correlation between shoulder strength deficits and shoulder function evaluated by various clinical scoring systems. A total of 262 patients (mean age, 59.67 years [standard deviation, 8.06 years]) who underwent full-thickness rotator cuff repair were included. Patients in group I (n = 188) had small to large rotator cuff tears, whereas those in group II (n = 74) had massive rotator cuff tears. Demographic factors, isokinetic test results, and shoulder function evaluated using various scoring systems were obtained. Correlation differences according to severity of the rotator cuff tear were evaluated. We found weak correlations between shoulder strength deficits (peak torque and total work) and clinical outcomes in patients with rotator cuff tears (r = -0.288). For patients in group I (nonmassive tears), we found a weaker correlation (r = -0.242) according to the tear pattern. However, shoulder strength deficits in group II patients (massive tears) were strongly correlated with American Shoulder and Elbow Surgeons (r = -0.598), Constant (r = -0.582), and Short Form 36 (r = -0.511) scores, especially regarding internal rotator strength deficits. Shoulder strength deficits measured via isokinetic testing and shoulder function were weakly correlated in patients with rotator cuff tears. However, shoulder strength deficits in patients with massive tears considerably worsened shoulder function and systemic disability, but not regional disability. In particular, internal rotator strength deficits were strongly correlated with poor shoulder function.

Modified frailty index predicts medical complications, length of stay, readmission, and mortality following total shoulder arthroplasty

17-06-2019 – Sophia A. Traven, Kathy M. McGurk, Russell A. Reeves, Zeke J. Walton, Shane K. Woolf, Harris S. Slone

Journal Article

The purpose of this study was to evaluate the 5-factor modified frailty index (m
FI-5) as a predictor of postoperative complications in patients undergoing total shoulder arthroplasty (TSA). We conducted a retrospective analysis of the National Surgical Quality Improvement Program database for patients undergoing TSA between the years 2005 and 2017. The m
FI-5 score, which includes the presence of comorbid diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functional status, was calculated for each patient. Multivariate logistic regression models were used to assess the relationship between the m
FI-5 and postoperative complications. A total of 18,957 patients undergoing TSA were identified. The m
FI-5 was a strong predictor of serious medical complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), discharge to a facility, and readmission (odds ratio ≥ 1.309, P ≤ .001). Length of stay also increased as the m
FI-5 score increased (P < .001). However, among all the measured complications, the m
FI-5 was the strongest predictor of mortality, with the risk more than doubling for each point increase in the m
FI-5 score (odds ratio, 2.113; 95% confidence interval, 1.447-3.086; P < .001). The m
FI-5 predicts serious medical complications, increased length of stay, discharge to a facility, hospital readmission, and mortality in patients undergoing TSA. All of the variables within the m
FI-5 are easily obtained through the patient history, allowing for a practical clinical tool that hospitals and surgeons can use to identify high-risk surgical candidates, inform preoperative counseling, and guide perioperative care to optimize patient outcomes.

Microbial colonization of subscapularis tagging sutures in shoulder arthroplasty: a prospective, controlled study

14-07-2019 – Ryan Roach, Stephen Yu, Hien Pham, Vinh Pham, Mandeep Virk, Joseph D. Zuckerman

Journal Article

Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

The effect of the subacromial balloon spacer on humeral head translation in the treatment of massive, irreparable rotator cuff tears: a biomechanical assessment

06-07-2019 – Supriya Singh, Jacob Reeves, G. Daniel G. Langohr, James A. Johnson, George S. Athwal

Journal Article

The current management of massive, irreparable rotator cuff tears is challenging, and no individual surgical technique has demonstrated clinical superiority. This study evaluated the role of a subacromial balloon spacer and its ability to depress the humeral head in the setting of a massive, irreparable rotator cuff tear. Eight cadaveric shoulders were tested. The specimens were mounted onto a shoulder simulator that applied muscle loading. Five shoulder states were tested: intact; irreparable rotator cuff tear; and inflation of the subacromial balloon spacer with 10, 25, and 40 m
L of saline solution on the irreparable rotator cuff tear. Humeral head migration was measured at 0°, 30°, 60°, and 90° of shoulder abduction. After creation of a massive, irreparable rotator cuff tear, in 0° of abduction, the humeral head migrated superiorly by a mean of 3.5 ± 0.7 mm compared with the intact shoulder state (P = .002). The subacromial balloon spacer inflated to 25 m
L translated the humeral head inferiorly relative to the torn state by an average of 3.2 ± 0.6 mm (P = .001) for all abduction angles. The balloon inflated to 10 m
L was ineffective at restoring humeral head position as it was still significantly superior than intact (P = .017). The balloon inflated to 40 m
L was successful in depressing the humeral head; however, it over-translated the humeral head anteroinferiorly, such that it was significantly different from the intact condition (P < .001). Overall, the 25-m
L balloon best restored the humeral head position. The results of this study demonstrate that the subacromial balloon spacer is most effective in depressing the humeral head and restoring the glenohumeral joint position when inflated to 25 m

Erratum to “A Biomechanical Cadaveric Study of Patella Tendon Allograft as an Alternative Graft Material for Superior Capsule Reconstruction” Jxa0Shoulder Elbow Surg 2018;28:1241-1248

22-09-2019 –

Published Erratum

High median nerve injury after arthroscopic elbow contracture release with complete recovery at 6 months

21-08-2019 – Marc J. ODonnell, Michael R. Hausman

Journal Article

Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI

08-07-2019 – Arno Frigg, David Song, Janick Willi, Andreas U. Freiburghaus, Holger Grehn

Journal Article

Asymptomatic acromioclavicular osteoarthritis (AC-OA) is a frequent finding in shoulder magnetic resonance imaging (MRI). Its natural course is unknown. Therefore, the question arises whether a resection should be performed simultaneously with shoulder surgery for another reason to prevent future pain and reoperation. The purpose of this study was to investigate the mid-term course of asymptomatic AC-OA. Overall, 114 asymptomatic AC-OA diagnosed on MRI were followed for 7 years between 2011 and 2018. At baseline, MRI signal enhancement in the clavicle and acromion, OA grade, physical demand as well as the parameters (1) Constant Score Visual Analogue Scale, (2) pain on AC-joint compression, and (3) cross-body adduction test were measured. All patients were followed up after 7 years by interview, and in case of symptoms by clinical examination. The endpoint “deterioration” was reached if 2 of the 3 parameters turned worse. Asymptomatic AC-OA remained asymptomatic in 83% of cases, 7% turned better, 10% turned worse. Physical demand and osteoarthritis grade increased the risk of deterioration, whereas MRI signal enhancement in the clavicle or acromion had no influence on outcome. During follow-up, the frequency of pain on AC-joint compression increased from 11% to 16% (P = .24), the frequency of a positive cross-body adduction test increased from 6% to 20% (P = .017), and the mean Constant Score Visual Analogue Scale increased from 10 to 13 points (P < .001) indicating less pain. Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. A simultaneous resection of an asymptomatic AC-OA during shoulder surgery for another reason is not indicated in every patient.

The value of shoulder replacement and rotator cuff surgery: the patients’ perspective

03-07-2019 – Grant Jamgochian, Joseph Abboud, Ryan Churchill, Grant Garrigues, Stephen Brockmeier, Tyler Bauer, Sameer Nagda

Journal Article

With the continued rise in health care costs, value-based care in orthopedics is more important than ever. Health care providers, policymakers, and insurance companies all have input into defining and setting the level of this value. The purpose of this study was to evaluate patient perception of value in rotator cuff repair (RCR) and total shoulder replacement (TSA) using a population composed only of patients who underwent the procedure. We were able to obtain complete data from 191 of the 250 patients in the RCR cohort and 211 of the 250 patients in the TSA cohort. Patients were asked what they believe a surgeon should be reimbursed for performing RCR or TSA, what they would be willing to pay for the procedure, and to rate the importance of each aspect of their care. Patients then estimated what Medicare reimbursed for the procedure they underwent. The mean result for patients surveyed regarding a reasonable fee for surgeons was $9870 for RCR and $14,231 for TSA. The mean patient estimate for actual Medicare reimbursement was $5705 for RCR and $9372 for TSA. Fifty-seven percent thought that payment for RCR was too low, and 76% thought that it was too low for TSA. When asked to rate the importance of each aspect of their care, RCR patients felt that 46% should go to the surgeon. TSA patients felt that surgeons should receive 47%. In agreement with prior studies, patients perceived the monetary value of RCR and TSA to be much higher than current Medicare schedules.

A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty

30-07-2019 – Jason K. Panchamia, Adam W. Amundson, Adam K. Jacob, Hans P. Sviggum, Ngoc Tram V. Nguyen, Joaquin Sanchez-Sotelo, John W. Sperling, Darrell R. Schroeder, Sandra L. Kopp, Rebecca L. Johnson

Journal Article

The ideal analgesic modality for total shoulder arthroplasty (TSA) remains controversial. We hypothesized that a multimodal analgesic pathway incorporating continuous interscalene blockade (ISB) provides better analgesic efficacy than both single-injection ISB and local infiltration analgesia. This single-center, parallel, unblinded, randomized clinical trial evaluated 129 adults undergoing primary TSA. Patients were allocated to single-injection ISB, continuous ISB, or local infiltration analgesia. The primary outcome was the Overall Benefit of Analgesia Score (range, 0 [best] to 28 [worst]) on postoperative day 1. Additional outcomes included pain scores, opioid consumption, quality of life, and postoperative complications in the first 24 hours, at 3 months, and at 1 year. We analyzed 125 patients (42 with single-injection ISB, 41 with continuous ISB, and 42 with local infiltration analgesia). The Overall Benefit of Analgesia Score was significantly improved in the continuous group (median [25th percentile, 75th percentile], 0 [0, 2]) compared with the single-injection group (2 [1, 4]; P = .002) and local infiltration analgesia group (3 [2, 4]; P < .001). Pain scores were significantly lower in the continuous group compared with the local infiltration analgesia group (P < .001 for all time points) and after 12 hours from ward arrival compared with the single-injection group (median [25th percentile, 75th percentile], 1.0 [0.0, 2.8] vs. 2.5 [0.0, 4.0]; P = .016). After postanesthesia recovery discharge, opioid consumption (oral morphine equivalents) was significantly lower in the continuous group (median [25th percentile, 75th percentile], 7.5 mg [0.0, 25.0 mg]) than in the local infiltration analgesia group (30 mg [15.0, 52.5 mg]; P < .001) and single-injection group (17.6 mg [7.5, 45.5 mg]; P = .010). No differences were found across groups for complications, 3-month outcomes, and 1-year outcomes. Continuous ISB provides superior analgesia compared with single-injection ISB and local infiltration analgesia in the first 24 hours after TSA.

Surgical management of chronic high-grade acromioclavicular joint dislocations: a systematic review

28-07-2019 – Paul Borbas, James Churchill, Eugene T. Ek

Journal Article, Review

To date, no gold-standard technique exists for the treatment of chronic acromioclavicular joint (ACJ) instability. We systematically reviewed the clinical results of 3 main categories of ACJ reconstruction for high-grade chronic instability. A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were clinical studies involving patients with ACJ instability (Rockwood grades III-VI) for at least 6 weeks, managed with ACJ stabilization, with a minimum 1-year follow-up. Depending on the surgical technique, patients were divided into 1 of 3 groups: nonbiological fixation between the coracoid and clavicle, for example, suture loops and synthetic ligaments (group 1); biological reconstruction of the coracoclavicular ligaments, for example, allograft or autograft ligament reconstruction (group 2); and ligament and/or tendon transfer, for example, the Weaver-Dunn procedure (group 3). Patient demographic characteristics, functional scores, radiographic outcomes, and complications were compared. Two independent investigators reviewed 960 articles. A total of 27 studies met the inclusion criteria, comprising 590 patients divided into 1 of 3 groups. The complication rates were similar among the 3 groups: 15% for nonbiological fixation, 15% for biological reconstruction, and 17% for ligament and/or tendon transfer, with failure rates of 8%, 7%, and 5%, respectively. In terms of functional results, the mean Constant score was 87.2 points for nonbiological fixation (n = 89), 92.4 points for biological reconstruction (n = 86), and 87.4 points for ligament and/or tendon transfer (n = 49). On comparison of the results of 3 different ACJ reconstruction methods, all techniques showed similar complication rates. Among the level II studies, ACJ reconstruction with a tendon graft showed superior results.

Mid-term results of reverse shoulder arthroplasty for glenohumeral osteoarthritis with posterior glenoid deficiency and humeral subluxation

14-08-2019 – Philippe Collin, Anthony Hervé, Gilles Walch, Pascal Boileau, Moganadass Muniandy, Mickael Chelli

Journal Article, Review

Results of anatomic shoulder arthroplasty for glenohumeral osteoarthritis with severe glenoid retroversion are unpredictable with a high rate of glenoid loosening. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative, with good early results. We sought to confirm this at longer follow-up (minimum 5 years). The study hypothesis was that early results would endure over time. We retrospectively reviewed all RSAs performed in 7 centers from 1998 to 2010. The inclusion criteria were primary glenohumeral osteoarthritis with B1, B2, B3, or C glenoid. Forty-nine shoulders in 45 patients fulfilled the criteria. Bone grafting was performed in 16 cases. Clinical outcomes were evaluated with the Constant score (CS) and shoulder range of motion. The mean total CS increased from 30 preoperatively to 68 points (P < .001) with significant improvements in all the subsections of the CS and range of motion. Scapular notching was observed in 20 shoulders (43%), grade 1 in 5 (11%), grade 2 in 7 (15%), grade 3 in 5 (11%), and grade 4 in 3 (6%). The glenoid bone graft healed in all the shoulders. Partial inferior lysis of the bone graft was present in 8 cases (50%). Scapular notching and glenoid bone graft resorption had no influence on the CS (P = .147 and P = .798). RSA for the treatment of primary glenohumeral osteoarthritis in patients with posterior glenoid deficiency and humeral subluxation without rotator cuff insufficiency resulted in excellent clinical outcomes at a minimum of 5 years of follow-up.

Surgical approaches for total elbow arthroplasties using data from the Dutch Arthroplasty Register

17-06-2019 – Ante Prkić, Koen L.M. Koenraadt, Jetske Viveen, Liza van Steenbergen, Bertram The, Denise Eygendaal

Journal Article

Total elbow arthroplasty (TEA) is a relatively infrequently performed procedure. Therefore, nationwide databases help to provide more insight into factors that might influence implant survival, for example, the surgical approach used. Using data from the Dutch Arthroplasty Register, we aimed to reveal whether high-volume centers use different approaches than low-volume centers and whether the approach is implant specific. Using data from 2014 to 2017, we compared the surgical approaches used for high- vs. low-volume centers, as well as for the 2 most frequently used types of TEA, by use of χ We analyzed 276 procedures. In 2016 and 2017, when posterior approaches were further specified, the triceps-on approach was used most frequently in the high-volume center (27 of 42 procedures, 64%) and the triceps-flap approach was used most often in the low-volume centers (48 of 84 procedures, 57%) (P < .001). For the 2 most frequently used types of TEA, the Coonrad-Morrey and Latitude EV arthroplasties, the surgical approaches did not differ. When the high-volume center was compared with the low-volume centers, implant choice differed, with the Coonrad-Morrey arthroplasty being most often used in the high-volume center and the Latitude EV arthroplasty, in the low-volume centers. The posterior triceps-flap approach was the most frequently used surgical approach in primary TEA in the Netherlands, yet the triceps-on approach was used more often in the high-volume center. The surgical approaches did not differ between the 2 most frequently used types of TEA in the Netherlands.

Treatment of posteromedial and posterolateral dislocation of the acute unstable elbow joint: a strategic approach

22-09-2019 – Jung Hyun Lee, Ji-Ho Lee, Kyung Chul Kim, Kee Baek Ahn, In Hyeok Rhyou

Journal Article

The purpose of this study was to evaluate the different treatment strategies for posterolateral and posteromedial elbow dislocation. The study enrolled 21 patients with unstable simple elbow dislocation including 16 cases of posterolateral dislocation (PLDL) and 5 cases of posteromedial dislocation (PMDL). In patients with PLDL, the medial side was evaluated and repaired first, followed by the lateral side. In patients with PMDL, the lateral side was repaired first, followed by the medial side according to residual instability. Among the 16 cases of unstable PLDL, 7 of 9 presenting with complex combined tear of the ulnar collateral ligament (UCL) and flexor muscle on magnetic resonance imaging showed abnormality on valgus stress testing and UCL repair. Three of 7 cases required additional lateral collateral ligament complex (LCLC) repair. Two of 9 cases showing medial complex dual lesions had normal findings on valgus stress testing and were treated only with LCLC repair. Seven of 16 cases without medial complex dual lesion had normal findings on valgus stress testing, and only LCLC repair was performed. All 5 cases of unstable PMDL showed distraction-type LCLC injury on magnetic resonance imaging and required no additional UCL repair after LCLC repair. There were no cases of recurrent instability following this treatment algorithm. In unstable elbow dislocation, PLDL and PMDL are caused by different mechanisms following damage to different structures. Therefore, different strategies are needed to ameliorate the dislocation and instability.

Surgical outcomes for post-traumatic stiffness after elbow fracture: comparison between open and arthroscopic procedures for intra- and extra-articular elbow fractures

22-09-2019 – Jae-Man Kwak, Yucheng Sun, Erica Kholinne, Kyoung-Hwan Koh, In-Ho Jeon

Journal Article

We hypothesized that arthroscopic osteocapsular arthroplasty has a comparable outcome to that of the corresponding open procedure. Patients treated with osteocapsular arthroplasty for post-traumatic stiffness were assigned to open procedure (OPEN) and arthroscopic procedure (ARTHRO) groups. The clinical outcomes were measured based on range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) score. Based on the initial trauma, the patients were grouped into either intra-articular fracture (I) or extra-articular fracture (E) groups, followed by comparison of the 2 groups. The overall, ROM, VAS, and MEPS scores showed improvement in both groups. Preoperative VAS scores improved from 6.6 ± 1.4 to 2.2 ± 0.9 following OPEN and from 6.5 ± 1.2 to 2.1 ± 1.0 following ARTHRO. Preoperative flexion improved from 88° ± 14° to 113° ± 17° following OPEN and from 102° ± 15° to 122° ± 8° following ARTHRO. Preoperative extension improved from 36° ± 14° to 17° ± 12° following OPEN and from 30° ± 8° to 15° ± 7.4° following ARTHRO. Preoperative MEPS improved from 48.9 ± 11.5 to 80.0 ± 14.8 following OPEN and from 52.3 ± 12.2 to 80.8 ± 7.9 following ARTHRO. All values for the clinical outcomes were worse in group I than in group E. Arthroscopic osteocapsular arthroplasty is comparable to the corresponding open procedure with regard to the use of our indications. The clinical outcomes in the intra-articular fracture group as a previous trauma were worse than those in the extra-articular fracture group.

Arthroscopic glenoid labral lesion repair using all-suture anchor for traumatic anterior shoulder instability: short-term results

19-05-2019 – Orkun Gül, Ahmet Emin Okutan, Muhammet Salih Ayas

Journal Article

This study presents the preliminary clinical results of arthroscopic glenoid labral lesion repair using all-suture anchors in the treatment of recurrent traumatic anterior shoulder instability. Seventy patients who underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability were evaluated in this single center-based retrospective study. Patients with a glenoid defect greater than 20%, off-track engaging Hills-Sachs lesion, multidirectional instability, and generalized ligamentous laxity were excluded. The 62 included patients treated with arthroscopic glenoid labral lesion repair using all-suture anchors were evaluated. The Rowe and Constant scores were used to assess the results. We evaluated 62 patients with a mean age of 26.7 ± 12 years. The mean Rowe and Constant scores were 35 ± 7.2 and 65 ± 6.3, respectively, preoperatively and increased to 93.6 ± 5.3 and 92 ± 4.3, respectively, postoperatively at the mean follow-up of 28.8 months (range, 24-48 months) (P < .001). The redislocation rate was 8.1%. Of the patients, 91.9% had good to excellent clinical scores. Younger age and contact sports were associated with a higher risk of recurrent dislocation (P = .012 and P = .041, respectively). The postoperative functional results were not significantly correlated with the findings concerning the number of dislocations, time until surgery, degree of anterior translation, and number of anchors. The use of all-suture anchors for arthroscopic glenoid labral lesion repair for the treatment of recurrent traumatic anterior shoulder instability yields satisfactory clinical results and is a safe and effective option.

Development of the glenohumeral joint after subscapular release and open relocation in children with brachial plexus birth palsy: long-term results in 61 patients

16-05-2019 – Krister Jönsson, Michael Werner, Fredrik Roos, Tomas Hultgren

Journal Article

We present the long-term results of remodeling of the glenohumeral joint after open subscapularis elongation and relocation of the humeral head in patients with an internal rotation contracture and joint incongruity due to brachial plexus birth palsy. In this before-and-after study, 61 patients who underwent open subscapularis elongation and reduction of the glenohumeral joint were evaluated with respect to joint remodeling, with a mean follow-up period of 10.2 years (range, 7-16 years). The mean age at operation was 3.2 years (range, 8 months to 15 years). Measurements of the percentage of the humeral head anterior to the midscapular line (PHHA), glenoid version, and diameter of the humeral head were recorded using magnetic resonance imaging, comparing the affected joints preoperatively vs. postoperatively (n = 31) and comparing the operated vs. unaffected sides postoperatively (n = 61). The mean increase in PHHA was 27.6 percentage points (95% confidence interval, 22.4-32.7 percentage points; P < .01), from 13.2% to 40.8%. The glenoid retroversion changed by 14.8° (95% confidence interval, 11.1°-18.4°; P < .01), from 25.4° to 10.6°, approaching a normal value. All patients, even those older than 5 years, showed a clear benefit from surgery. Our study confirms that open subscapularis lengthening with joint repositioning, up to the age of 5 years, gives consistent remodeling of incongruent shoulders with surprisingly small differences between the operated and unaffected shoulders at long-term follow-up. The findings indicate that open reduction is useful also in adolescents and challenges the notion that older children should be treated with derotational humeral osteotomy.

The primary cost drivers of arthroscopic rotator cuff repair surgery: a cost-minimization analysis of 40,618 cases

17-06-2019 – Lambert Li, Steven L. Bokshan, Lauren V. Ready, Brett D. Owens

Journal Article

An estimated 250,000 rotator cuff repair (RCR) surgical procedures are performed every year in the United States. Although arthroscopic RCR has been shown to be a cost-effective operation, little is known about what specific factors affect the overall cost of surgery. This study examines the primary cost drivers of RCR surgery in the United States. Univariate analysis was performed to determine the patient- and surgeon-specific variables for a multiple linear regression model investigating the cost of RCR surgery. The 2014 State Ambulatory Surgery and Services Databases were used, yielding 40,618 cases with Current Procedural Terminology code 29827 (“arthroscopic shoulder rotator cuff repair”). The average cost of RCR surgery was $25,353. Patient-specific cost drivers that were significant under multiple linear regression included black race (P < .001), presence of at least 1 comorbidity (P < .001), income quartile (P < .001), male sex (P = .012), and Medicare insurance (P = .035). Surgical factors included operative time (P < .001), use of regional anesthesia (P < .001), quarter of the year (January to March, April to June, July to September, and October to December) (P < .001), concomitant subacromial decompression or distal clavicle excision (P < .001), and number of suture anchors used (P < .001). The largest cost driver was subacromial decompression, adding $4992 when performed alongside the RCR. There are several patient-specific variables that can affect the cost of RCR surgery. There are also surgeon-controllable factors that significantly increase cost, most notably subacromial decompression, distal clavicle excision, use of regional anesthesia, and number of suture anchors. Surgeons must consider these factors in an effort to minimize cost, particularly as bundled payments become more common.

Arthroscopy of the symptomatic shoulder arthroplasty

16-05-2019 – Ciaran Doherty, Nicholas D. Furness, Timothy Batten, William J. White, Jeffrey Kitson, Christopher D. Smith

Journal Article

Assessment of a painful or stiff shoulder arthroplasty can be challenging. The cause of pain can sometimes be easily identified. However, some patients have normal levels of inflammatory markers, normal plain films, and no clinical signs to indicate a diagnosis. Indolent organisms may not raise blood marker levels or result in obvious radiologic findings such as loosening. We report the utility of performing arthroscopy in these patients for a diagnostic advantage. We retrospectively reviewed the health records of all patients who underwent diagnostic shoulder arthroscopy over a 3-year period. Patients were included if they were aged 18 years or older, had undergone previous arthroplasty surgery, and had symptoms of shoulder pain or stiffness. Patients were excluded if they had any traditional symptoms of infection or had a raised serum white cell count or C-reactive protein level prior to diagnostic arthroscopy. Fourteen patients met the initial inclusion criteria. The mean interval between index surgery and arthroscopic evaluation was 65.4 months (standard deviation, 58 months; range, 17-192 months). Arthroscopic biopsy specimens returned positive culture results in 3 patients (21%). Rotator cuff tears were noted in 8 patients (57%). Capsular contraction requiring release was noted in 2 patients (10%). In all patients, the diagnostic arthroscopy directed the next stage of management. Diagnostic arthroscopy allows a full assessment of implants, the rotator cuff, the native articular surfaces, and scar tissue, as well as biopsy specimens to be obtained for indolent infection, in patients considering revision arthroplasty surgery. This allows a more informative consent process for patients, directs surgical management, and on occasion, allows for therapeutic intervention in a painful or stiff shoulder arthroplasty.

The radiographic morphology of the greater tuberosity is associated with muscle degeneration in patients with symptomatic rotator cuff tears

17-06-2019 – Hao-Chun Chuang, Chih-Kai Hong, Kai-Lan Hsu, Fa-Chuan Kuan, Cheng-Li Lin, Wei-Ren Su

Journal Article

Atrophy and fatty infiltration of the rotator cuff muscles portend poor findings in terms of postoperative function and the probability of retears. We assumed that sclerosis and spurs of the greater tuberosity (GT) on radiographs are associated with this rotator cuff muscle degeneration. We retrospectively reviewed the preoperative radiographs and magnetic resonance (MR) images of 91 shoulders (average age of patients, 59.7 years; age range, 36-79 years) arthroscopically repaired between 2012 and 2016. The radiographic morphology of the GT was defined as normal, sclerotic, or spurring. Atrophy and fatty infiltration of the rotator cuff muscles were evaluated using the occupation ratio and Goutallier classification, respectively, via the MR images. Diagnoses of rotator cuff tears were made during arthroscopic shoulder surgery. Significant associations between the radiographic GT morphology and the severity of both supraspinatus muscle atrophy (P = .002) and infraspinatus muscle atrophy (P = .047) were found. The mean occupation ratios of both the sclerotic GT group and the spurring GT group were significantly reduced compared with the mean occupation ratio of the normal GT group. Patients with GT spurs were found to be prone to severe supraspinatus fatty degeneration (P = .020). For patients with rotator cuff tears, the presence of GT spurs or sclerosis on radiographs predicted the occurrence of supraspinatus and infraspinatus muscle atrophy, as well as supraspinatus fatty infiltration, based on MR images. The clinical relevance is that MR imaging is suggested for patients with radiographic GT sclerosis or spurs to detect advanced rotator cuff lesions.

Glenoid component lucencies are associated with poorer patient-reported outcomes following anatomic shoulder arthroplasty

17-06-2019 – Bradley S. Schoch, Thomas W. Wright, Joseph D. Zuckerman, Charlotte Bolch, Pierre-Henri Flurin, Chris Roche, Joseph J. King

Journal Article

High rates of radiographic glenoid loosening following anatomic total shoulder arthroplasty (TSA) are documented at midterm follow-up. Small studies remain conflicted on the impact of lucent lines on clinical outcomes. This study assesses the impact of radiolucent lines on function and patient-reported outcomes (PROs) following TSA. We retrospectively evaluated 492 primary TSAs performed between February 2005 and April 2016. Radiographs were evaluated for glenoid loosening according to the Lazarus grade at a mean of 5.3 years (range, 2-12 years). Clinical outcome measures included range of motion and American Shoulder and Elbow Surgeons, Constant, University of California-Los Angeles, Simple Shoulder Test, and Shoulder Pain and Disability Index scores. Outcomes were compared between patients with and patients without glenoid lucent lines and in relation to lucency grade. At most recent follow-up, 308 glenoids (63%) showed no radiolucent lines (group 0) and 184 demonstrated peri-glenoid lucencies (group 1). The groups were similar regarding age, sex, body mass index, comorbidities, and prior surgery. At follow-up, group 1 demonstrated significantly lower improvements in forward elevation (P = .02) and all PROs (P ≤ .005). Subgroup analysis by radiolucency grade showed that forward elevation diminished with increasing radiolucent score and exceeded the minimal clinically important difference (MCID) above grade 2 lucencies. A similar decline in PROs was observed with increasing lucency grade. These differences did not exceed the MCID below grade 5 lucencies. Peri-implant glenoid lucencies following TSA are associated with lower forward elevation and PROs. Lucencies above grade 2 are associated with clinically important losses in overhead motion. However, differences below the MCID are maintained for PROs below grade 5 glenoid lucencies.

Outcomes of anatomic total shoulder arthroplasty in patients with excessive glenoid retroversion: a case-control study

23-06-2019 – Paul DeVito, Kofi D. Agyeman, Hyrum Judd, Molly Moor, Derek Berglund, Andy Malarkey, Jonathan C. Levy

Journal Article

Ideal management of severe glenoid retroversion during anatomic total shoulder arthroplasty (TSA) remains controversial, as previous reports have suggested that severe retroversion may negatively impact clinical outcomes. The purpose of this study was to evaluate the impact of severe glenoid retroversion on clinical and radiographic TSA outcomes using a standard glenoid component, as well as to compare outcomes among patients with less severe retroversion. A case-control study was performed comparing 40 patients treated with TSA with more than 20° of glenoid retroversion preoperatively (average follow-up, 53 months) vs. a matched cohort of 80 patients with less than 20° of retroversion (average follow-up, 49 months). In all patients, the surgical technique, implant design, and postoperative rehabilitation protocol were identical. Patients were matched based on sex, age, indication, and prosthetic size. Comparisons were made regarding patient-reported outcome measures (PROMs), motion, postoperative radiographic loosening, and the presence of medial calcar resorption. Preoperatively, both groups demonstrated similar PROMs and measured motion, except for preoperative Single Assessment Numeric Evaluation scores and American Shoulder and Elbow Surgeons total scores, which were higher for the severe retroversion group (44.4 vs. 31.3 [P = .012] and 34.9 vs. 29.4 [P = .048], respectively). Postoperative PROMs and motion were also similar between the 2 cohorts. No significant differences were observed for postoperative radiographic findings. Medial calcar resorption was identified in 74 patients (61.7%). Calcar resorption and individual resorption grades were not found to differ significantly. At midterm follow-up, preoperative severe glenoid retroversion does not appear to influence clinical or radiographic outcomes of TSA using a standard glenoid component.

Attitudes and awareness of suture anchor cost: axa0survey of shoulder surgeons performing rotator cuff repairs

02-10-2019 – John Johnson, Martim Pinto, Eugene Brabston, Amit Momaya, Samuel Huntley, Jun Kit He, Gerald McGwin, Wesley Phipatanakul, John Tokish, Brent A. Ponce

Journal Article

The cost of health care in the United States accounts for 18% of the nation’s gross domestic product and is expected to reach 20% by 2020. Physicians are responsible for 60%-80% of decisions resulting in health care expenditures. Rotator cuff repairs account for $1.2-$1.6 billion in US health care expenditures annually. The purpose of this study is to assess surgeons’ cost awareness in the setting of rotator cuff repairs. The hypothesis is that practice environment and training affect cost consciousness and incentivization will lead to more cost-effective choices. In this cross-sectional study, a 21-item survey was distributed via the email list services of the American Shoulder and Elbow Surgeons and Arthroscopy Association of North America. Data collected included demographics, variables regarding rotator cuff repair (technique, number of companies used, procedures per month), and knowledge of costs. Responses from 345 surgeons in 23 countries were obtained with the majority (89%) being from the United States. Most surgeons were “cost-conscious” (275, 70.7%). Of these surgeons, 62.9% are willing to switch suture anchors brands to reduce overall costs if incentivized. Cost-conscious surgeons were more likely to be fellowship trained in shoulder and elbow (51.81% vs. 38.57%, P = .048), be paid based on productivity (73.53% vs. 61.43%, P = .047), and receive shared profits (85.4% vs. 75%, P = .02). The majority of orthopedic surgeons are both cost-conscious and willing to change their practice to reduce costs if incentivized to do so. A better understanding of implant costs combined with incentives may help reduce health care expenditure.

Post-traumatic proximal radioulnar synostosis: results of surgical treatment and review of the literature

02-10-2019 – Giuseppe Giannicola, Paolo Spinello, Ciro Villani, Gianluca Cinotti

Journal Article

Post-traumatic proximal radioulnar synostosis is a very rare and disabling condition whose surgical treatment has traditionally been viewed with pessimism. The results of the few case series in the literature are conflicting. Our aims were (1) to describe the clinical results of a case series treated surgically by a single elbow surgeon and (2) to review the literature. Twelve patients were evaluated. Preoperative radiographs and computed tomography scans were performed. According to the Viola and Hastings classification, there was 1 case of type IC synostosis; 3, type IIA; 2, type IIIA; and 8, type IIIB. Two patients had a double synostosis. The synostosis was excised in 10 cases; in addition, radial head excision, radial head arthroplasty, and proximal radial diaphyseal resection were performed in 1, 3, and 2 cases, respectively. The Mayo Elbow Performance Score, modified American Shoulder and Elbow Surgeons score, and Quick
DASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were used for the preoperative and postoperative evaluation. The nonparametric Wilcoxon signed rank test was used for the statistical analysis. The mean follow-up period was 20.5 months. The final mean extension-flexion and pronation-supination arcs were 116° and 123°, respectively. Significant improvements were found in the Mayo Elbow Performance Score (P = .005), modified American Shoulder and Elbow Surgeons score (P = .012), and Quick
DASH score (P = .002), with mean values of 24, 28, and 17, respectively. One synostosis recurrence and one late disassembly of the radial head arthroplasty were observed. Post-traumatic proximal radioulnar synostosis surgery is effective, but careful preoperative planning based on the pathoanatomic characteristics of each type of synostosis and associated lesions is mandatory. Synostosis excision is performed in most cases, whereas additional surgical procedures should be considered in selected cases.

Can handheld dynamometry predict rotator cuff tear size? A study in 2100 consecutive patients

01-10-2019 – Anthony P. Klironomos, Patrick H. Lam, Judie R. Walton, George A.C. Murrell

Journal Article

This study aimed to determine whether handheld dynamometry measurements could predict rotator cuff tear size in patients who required surgical treatment of their shoulder pathology. Handheld dynamometer readings were collected prior to surgery and analyzed retrospectively for 2100 consecutive patients. Post hoc, the cohort was divided into patients with rotator cuff tears (n = 1747) and those without rotator cuff tears (n = 353). The tear group was stratified into partial- vs. full-thickness tears and into 4 groups based on tear size area. Patients with partial-thickness tears had greater internal rotation (P = .03), external rotation (P < .001), and supraspinatus (P < .001) strength than patients with full-thickness tears. Patients with tears had lower supraspinatus strength than patients without tears (r = -0.82, P < .001). Patients with a larger tear size had lower values of external rotation (r = -1.46, P < .001) and supraspinatus (r = -1.18, P < .001) strength. A model involving internal rotation and supraspinatus strength could predict the presence of a tear with a sensitivity of 82% and specificity of 29%. The correct prediction rate was 73% overall (82% in tear group and 29% in no-tear group). The following formula was found to predict rotator cuff tear size, showing modest correlation with our raw data (r = 0.25, P < .001): Tear size = 482.8 + (3.9 × Internal rotation strength) + (1.6 × Adduction strength) – (7.2 × External rotation strength) – (2.0 × Supraspinatus strength). Handheld dynamometer readings could not reliably predict rotator cuff tear size, showing only modest correlation with our raw data. Handheld dynamometry readings could predict the presence of a tear, although tears in the intact cohort were overestimated (a specificity of 29% and negative predictive value of 25%).

Comparison of best-fit circle versus contralateral comparison methods to quantify glenoid bone defect

01-10-2019 – Karthikraj Kuberakani, Kazuho Aizawa, Nobuyuki Yamamoto, Kiyotsugu Shinagawa, Takayuki Suzuki, Taku Hatta, Jun Kawakami, Eiji Itoi

Journal Article

Several measurement techniques have been reported to quantify glenoid bone defect in patients with anterior shoulder instability. Among them, the method that uses a best-fit circle and another that uses the contralateral glenoid as a control are most commonly used. However, to our knowledge, no study has been reported that compared the reliability of these methods. The purpose of this study, therefore, was to determine which of these methods has higher reproducibility. In this study, 3-dimensional computed tomography data from 94 patients (mean age 29 years) with unilateral anterior shoulder instability were used. Three examiners measured the glenoid bone defect of each patient 3 times using 2 techniques: the best-fit circle method and the contralateral comparison method. Intra- and interobserver reliabilities were measured using intraclass correlation coefficient (ICC). The intraobserver reliability was found to be 0.91 for the best-fit circle method and 0.98 for the contralateral comparison method. The interobserver reliability was 0.77 for the best-fit circle method and 0.88 for the contralateral method. The percentage of glenoid defect was 11.5% when using the best-fit circle and 10.7% with the contralateral method. The contralateral comparison method was more reliable than the best-fit circle method for quantifying the amount of glenoid bone loss.