Journal of Shoulder and Elbow Surgery

Journal of Shoulder and Elbow Surgery

Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway

11-05-2019 – Daniel P. Leas, Patrick M. Connor, Shadley C. Schiffern, Donald F. D’Alessandro, Katherine M. Roberts, Nady Hamid

Journal Article

Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty. Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls. Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required “rescue” opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment. An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.

Erratum to “Long-term Outcome of Custom Triflange Outrigger Ulnar Component in Revision Total Elbow Arthroplasty” J Shoulder Elbow Surg 2018;27:2045-2051

14-07-2019 –

Published Erratum

Long-term results of closed-wedge osteotomy of the lateral humeral condyle for osteochondritis dissecans of the capitellum

22-07-2019 – Hisao Koda, Koji Moriya, Masato Ueki, Naoto Endo, Takae Yoshizu

Journal Article

Various surgical methods are used for osteochondritis dissecans of the capitellum; however, we have consistently performed a closed-wedge osteotomy of the lateral humeral condyle since 1983. The purpose of this study is to clarify the long-term results of closed-wedge osteotomy for osteochondritis dissecans of the capitellum. Seventy-seven elbows with all lesion types of osteochondritis dissecans of the capitellum were treated with closed-wedge osteotomy. Unstable osteochondral fragments were fixed with a bone graft and bone pegs in combination with osteotomy. The mean age of the patients was 14.0 years. The patients were clinically and radiographically evaluated at a median value of 9.0 years after surgery. The range of elbow motion and standard deviation were increased significantly from 119° ± 22° preoperatively to 131° ± 18° postoperatively (P < .001). The Timmerman and Andrews score were improved significantly from 141 ± 26 points preoperatively to 184 ± 21 points postoperatively (P < .001). The Timmerman and Andrews score and the range of elbow motion at final examination in patients with preoperative osteoarthritic changes were significantly inferior to those in patients without preoperative osteoarthritic changes. Good remodeling of the capitellar lesions was radiographically observed in 53 elbows (69%). In the long-term follow-up evaluation, although 41 elbows (53%) had advanced osteoarthritic changes that were classified as grade II or III, disease progression was controlled in most of these cases. Good or excellent long-term clinical results were maintained in most of our patients. Closed-wedge osteotomy of the lateral humeral condyle is a useful method that can provide acceptable long-term clinical results.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older

03-05-2019 – Peter Domos, Enricomaria Lunini, Francesco Ascione, Nicola Serra, Michael J. Bercik, Lionel Neyton, Arnaud Godeneche, Gilles Walch

Journal Article

The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization. A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations. Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients. The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Effect of interscalene nerve block on the inflammatory response in shoulder surgery: a randomized trial

23-06-2019 – Gabriel Enrique Mejía-Terrazas, Michell Ruíz-Suárez, Felipe Vadillo-Ortega, Rebecca Elizabeth Franco y Bourland, Eunice López-Muñoz

Journal Article

Comparing techniques of general anesthesia and regional anesthesia in arthroscopic shoulder surgery, some studies have shown differences in the intensity of immediate postoperative pain and neuroendocrine response, but the inflammatory response when using balanced general anesthesia (BGA) vs. an ultrasound-guided (USG) single-dose interscalene block (SDIB) has not been compared. In a single-center, prospective, randomized clinical trial, the inflammatory response of 2 groups of 10 patients scheduled to undergo arthroscopic shoulder surgery was evaluated through measurement of a panel of cytokines that act on cells of the adaptive immune response to promote or inhibit inflammation, chemokines involved in chemotaxis, the erythrocyte sedimentation rate (ESR), the high-sensitivity C-reactive protein (CRP) level, and the white blood cell (WBC) count in 3 blood samples (before anesthesia, immediately postoperatively, and 24 hours postoperatively) with 2 types of anesthesia (BGA vs. USG SDIB). Postoperative pain intensity (immediately, at 12 hours, and at 24 hours) was also assessed. The ESR and CRP level increased significantly at 24 hours after surgery; however, the increase in ESR (P < .0001) and CRP level (P < .0001) was lower in the USG SDIB group. Significant increases in the levels of soluble interleukin 2 receptor α (P = .022) and interleukin 12p40 (P = .016) occurred in the immediate postoperative period in the USG SDIB group. Immediate postoperative pain showed a significant increase (P < .001) in the BGA group. In arthroscopic shoulder surgery, the use of a USG SDIB compared with the use of BGA is possibly associated with improved pain control in the immediate postoperative period and lower immunosuppression, even at 24 hours after surgery.

Efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis

22-07-2019 – Oluwadamilola Kolade, Karan Patel, Rivka Ihejirika, Daniel Press, Scott Friedlander, Timothy Roberts, Andrew S. Rokito, Mandeep S. Virk

Journal Article, Review

The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration’s tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, -1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, -0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

Screw configuration in proximal humerus plating has a significant impact on fixation failure risk predicted by finite element models

01-05-2019 – James W.A. Fletcher, Markus Windolf, R. Geoff Richards, Boyko Gueorguiev, Peter Varga

Journal Article

Proximal humeral fractures occur frequently, with fixed angle locking plates often being used for their treatment. No current quantitative evidence for the effect of different screw configurations exists, and the large number of variations makes biomechanical testing prohibitive. Therefore, we used an established and validated finite element osteosynthesis test kit to quantify the effect of variations in screw configuration on predicted failure risk of PHILOS plate fixation for unstable proximal humerus fractures. Twenty-six low-density humerus models were osteotomized to create malreduced unstable 3-part fractures that were virtually fixed with PHILOS plates. Twelve screw configurations were simulated: 6 using 2 screw rows, 4 using 3 rows, and 1 with either 8 or 9 screws. Three physiological loading cases were modeled and an established finite element analysis methodology was used. The average peri-screw bone strain, previously demonstrated to predict fatigue cutout failure, was used to compare the different configurations. Significant differences in peri-screw strains, and thus predicted failure risk, were seen with different combinations. The 9-screw configuration demonstrated the lowest peri-screw strains. Fewer screw constructs showed lower strains when placed further apart. The calcar screws (row E) significantly (P < .001) reduced fixation failure risk. Screw configurations significantly impact predicted cutout failure risk for locking plate fixations of unstable proximal humerus fractures in low-density bone. Although requiring clinical corroboration, the result of this study suggests that additional screws reduce peri-screw strains, the distance between them should be maximized whenever possible and the calcar screws should be used.

PROMIS physical function underperforms psychometrically relative to American Shoulder and Elbow Surgeons score in patients undergoing anatomic total shoulder arthroplasty

24-04-2019 – Michael C. Fu, Brenda Chang, Alexandra C. Wong, Benedict U. Nwachukwu, Russell F. Warren, David M. Dines, Joshua S. Dines, Frank A. Cordasco, Stephen Lyman, Lawrence V. Gulotta

Journal Article

The purpose of this study was to evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function computer adaptive test (PF-CAT) relative to the American Shoulder and Elbow Surgeons (ASES) score in patients with glenohumeral osteoarthritis undergoing primary anatomic total shoulder arthroplasty (TSA). A retrospective study of an institutional TSA registry was performed. Preoperative PROMIS PF-CAT and ASES scores were collected. Floor and ceiling effects were determined, and convergent validity was established through Pearson correlations. Rasch partial credit modeling was used for psychometric analysis of the validity of PF-CAT and ASES question items. Person-item maps were generated to characterize the distribution of question responses along the latent dimension of shoulder disability. Responses from 179 patients (184 shoulders) were included. PF-CAT had a moderate correlation to ASES (r = 0.487; P < .001), with no floor or ceiling effects; ASES had a 1.1% floor effect and no ceiling effect. With iterative Rasch model item-reduction analysis eliminating poorly fitting question items, all possible PF-CAT items were eliminated after 6 iterations. With ASES, just 1 function question item was dropped. Person-item maps showed ASES to be superior to PROMIS PF-CAT psychometrically, with sequential and improved coverage of the latent dimension of shoulder disability. Despite moderate correlation with ASES, PROMIS PF-CAT demonstrated inferior validity and psychometric properties in patients undergoing TSA. PF-CAT should not replace the ASES in this population of patients.

The Walch type B humerus: glenoid retroversion is associated with torsional differences in the humerus

03-05-2019 – Sumit Raniga, Nikolas K. Knowles, Emily West, Louis M. Ferreira, George S. Athwal

Journal Article

The Walch type B glenoid has the hallmark features of retroversion, joint subluxation, and bony erosion. Although the type B glenoid has been well described, the morphology of the corresponding type B humerus is poorly understood. As such, the aim of this imaging-based anthropometric study was to investigate humeral torsion in Walch type B shoulders. Three-dimensional models of the full-length humerus were generated from computed tomography data for the Walch type B group (n = 59) and for a control group of normal nonarthritic shoulders (n = 59). An anatomic humeral head-neck plane was created and used to determine humeral torsion relative to the epicondylar axis. Measurements were repeated, and intraclass correlation coefficients were calculated. The type B humeri had significantly (P < .001) less retrotorsion (14° ± 9°) than the control group (36° ± 12°) relative to the epicondylar axis. Male and female individuals within the control group showed statistically significant differences in humeral torsion (P = .043), which were not found in the type B group. Inter-rater reliability showed excellent agreement for humeral torsion (intraclass correlation coefficient, 0.962). A subgroup analysis between Walch type B2 and B3 shoulders showed no significant differences in any of the humeral or glenoid parameters. The Walch type B humerus has significantly less retrotorsion than non-osteoarthritic shoulders. At present, it is unknown whether the altered humeral retrotorsion is a cause or effect of the type B glenoid. In addition, it is unknown whether surgeons should be reconstructing type B2 humeral component version to pathologic torsion or to nonpathologic population means to optimize arthroplasty survivorship.

A new risk to the axillary nerve during percutaneous proximal humeral plate fixation using the Synthes PHILOSxa0aiming system

30-04-2019 – Khang H. Dang, Samuel S. Ornell, Guy Reyes, Michael Hussey, Anil K. Dutta

Journal Article

Percutaneous aiming arms have been developed to minimize injury during placement of submuscular proximal humerus plates. The purpose of this study was to determine the risk of axillary nerve injury during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system. By use of 10 fresh-frozen cadavers (20 shoulders), a 3.5-mm locking compression proximal humeral plate was fixated percutaneously to the humerus through a lateral deltoid-splitting approach using the PHILOS aiming guide. Dissection of the axillary nerve was then carried out, and measurements of its relation to the screw holes in row A through row G of the plate were taken. The lateral acromion-to-axillary nerve distance was also measured. The axillary nerve traversed row D in every shoulder, whereas it crossed over row C in 11 shoulders and both holes in row E in 16 shoulders. The closest distance to the axillary nerve achieved was 4.5 mm, corresponding to the distal (left) screw in row B. A significant negative correlation was found for the distance from the nerve to the closest proximal and distal screws (row B and row G, respectively) in both right shoulders (ρ = -0.797; 95% confidence interval, -0.916 to -0.548) and left shoulders (ρ = -0.615; 95% confidence interval, -0.831 to -0.237). The axillary nerve traverses rows C, D, and E of the proximal humeral plate using the PHILOS aiming system. Importantly, our study is the first to demonstrate that the axillary nerve crosses over row C. Left-sided plate screws also came in closer proximity to the axillary nerve than right-sided plate screws.

Sensory innervation of the subacromial bursa by the distal suprascapular nerve: a new description of its anatomic distribution

01-05-2019 – Pierre Laumonerie, Laurent Blasco, Meagan E. Tibbo, Nicolas Bonnevialle, Marc Labrousse, Patrick Chaynes, Pierre Mansat

Journal Article

Sensory innervation to the shoulder provided by the distal suprascapular nerve (d
SSN) remains the subject of debate. The purpose of this study was to establish consensus with respect to the anatomic features of the sensory branches of the d
SSN. The relevant hypothesis was that the d
SSN would give off 3 sensory branches providing innervation to the posterior glenohumeral (PGH) capsule, the subacromial bursa, in addition to the coracoclavicular and acromioclavicular ligaments. The division, course, and distribution of the sensory branches that originated from the d
SSN and innervated structures around the shoulder joint were examined macroscopically by dissecting 37 shoulders of 19 fresh-frozen cadavers aged of 83.0 years (range, 74-98 years). The 37 d
SSN provided 1 medial subacromial branch (MSAb), 1 lateral subacromial branch (LSAb), and 1 PGH branch (PGHb) to the shoulder joint. This arrangement allowed for bipolar-MSAb and LSAb-innervation of the subacromial bursa, acromioclavicular (MSAb and LSAb) and coracoclavicular (MSAb) ligaments, as well as the PGH capsule (PGHb). The d
SSN provided 2 subacromial branches and 1 PGHb to the shoulder joint. This arrangement allowed for bipolar-MSAb and LSAb-innervation of the subacromial bursa, acromioclavicular and coracoclavicular ligaments, as well as the PGH capsule.

Tendon contains more stem cells than bone at the rotator cuff repair site

01-05-2019 – T. Mark Campbell, Peter Lapner, F. Jeffrey Dilworth, M. Adnan Sheikh, Odette Laneuville, Hans Uhthoff, Guy Trudel

Journal Article

The rotator cuff (RC) repair failure rate is high. Tendon and bone represent sources of mesenchymal stem cells (MSCs), but the number of MSCs from each has not been compared. Bone channeling may increase bone-derived MSC numbers participating in enthesis re-formation at the “footprint” repair site. The effect of preoperative channeling on increasing bone MSC numbers has never been reported. We asked (1) whether bone contains more MSCs than tendon at the time of arthroscopic repair and (2) whether bone preoperative channeling at the RC repair site increases the number of bone-derived MSCs at the time of surgery. In 23 participants undergoing arthroscopic RC repair, bone was sampled from the footprint and tendon was sampled from the distal supraspinatus. We randomized participants to the channeling or no-channeling group 5 to 7 days before surgery. We enumerated MSCs from both tissues using the colony-forming unit-fibroblast (CFU-F) assay (10 per group). We identified MSC identity using flow cytometry and MSC tri-differentiation capacity (n = 3). Tendon CFU-F per gram exceeded bone CFU-F per gram for both groups (479 ± 173 CFU-F/g vs. 162 ± 54 CFU-F/g for channeling [P = .036] and 1334 ± 393 CFU-F/g vs. 284 ± 88 CFU-F/g for no channeling [P = .009]). Ninety-nine percent of cultured cells satisfied the MSC definition criteria. The distal supraspinatus tendon contained more MSCs per gram than the humeral footprint. Tendon may represent an important and overlooked MSC source for postoperative enthesis re-formation. Further studies are needed to evaluate the repair role of tendon MSCs and to recommend bone channeling in RC repair.

The effect of vitamin E–enhanced cross-linked polyethylene on wear in shoulder arthroplasty—a wear simulator study

29-04-2019 – Justin J. Alexander, Simon N. Bell, Jennifer Coghlan, Reto Lerf, Frank Dallmann

Journal Article

Wear of the polyethylene glenoid component and subsequent particle-induced osteolysis remains one of the most important modes of failure of total shoulder arthroplasty. Vitamin E is added to polyethylene to act as an antioxidant to stabilize free radicals that exist as a byproduct of irradiation used to induce cross-linking. This study was performed to assess the in vitro performance of vitamin E-enhanced polyethylene compared with conventional polyethylene in a shoulder simulator model. Vitamin E-enhanced, highly cross-linked glenoid components were compared with conventional ultrahigh-molecular-weight polyethylene glenoids, both articulating with a ceramic humeral head component using a shoulder joint simulator over 500,000 cycles. Unaged and artificially aged comparisons were performed. Volumetric wear was assessed by gravimetric measurement, and wear particle analysis was also subsequently performed. Vitamin E-enhanced polyethylene glenoid components were found to have significantly reduced wear rates compared with conventional polyethylene in both unaged (36% reduction) and artificially aged (49% reduction) comparisons. There were no differences detected in wear particle analysis between the 2 groups. Vitamin E-enhanced polyethylene demonstrates improved wear compared with conventional polyethylene in both unaged and artificially aged comparisons and may have clinically relevant benefits.

The morphologicxa0change of the elbow with flexion contracture in upper obstetric brachial plexus palsy

03-05-2019 – Kunihiro Oka, Tsuyoshi Murase, Hiroyuki Tanaka, Hidehiko Kawabata

Journal Article

Contracture of the elbow after obstetric brachial plexus palsy (OBPP) is well known; however, details of the 3-dimensional (3D) morphologic changes in the elbow joint in OBPP have not been clarified. This study aimed to clarify the 3D morphologic changes in the elbow joint by focusing on the distal humerus with flexion contracture in upper OBPP. We tested the hypothesis that the shape of the distal humerus with flexion contracture in upper OBPP is hypoplastic in the trochlea, capitellum, and olecranon fossa. We retrospectively studied 20 patients with elbow flexion contracture and residual OBPP. The approximate radius of the distal humerus, the shortest distance between the olecranon and coronoid fossa, and the size of the olecranon fossa were measured and compared between the affected and normal sides using 3D bone models to assess the distal humerus morphology. The average radius of the distal humerus was smaller on the affected side than on the normal side. Furthermore, the average distance between the olecranon and coronoid fossa was greater and the average size of the olecranon fossa was smaller on the affected side than on the normal side. The size of the distal humerus was significantly smaller and the olecranon fossa was significantly shallower on the affected side. Consistent with our original hypothesis, the distal humerus with flexion contracture in upper OBPP was hypoplastic. The shallow olecranon fossa might prevent full extension of the elbow even though soft tissue contracture release is performed. We recommend evaluation of the morphology of the olecranon fossa to determine the treatment plan for elbow flexion contracture with OBPP.

Ulnar collateral ligament insufficiency affects cubital tunnel syndrome during throwing motion: a cadaveric biomechanical study

06-05-2019 – Teruhisa Mihata, Masaki Akeda, Michael Künzler, Michelle H. McGarry, Masashi Neo, Thay Q. Lee

Journal Article

In throwing athletes, cubital tunnel syndrome and insufficiency of the ulnar collateral ligament (UCL) are common pathologic processes of the elbow. The objective of this study was to investigate the effect of UCL tears on ulnar nerve elongation in the simulated throwing position. Eight fresh frozen cadaveric upper limbs were tested at the simulated late cocking to acceleration phase in the throwing motion using an elbow testing system. Elbow valgus laxity and ulnar nerve length and strain under 2 Nm of applied valgus torque (maximum torque in cadaveric elbow) were evaluated. Paired t-tests were used to compare all data between intact UCLs and UCLs after complete transection of the anterior oblique ligament. Linear regression analysis was used to investigate relationships between elbow valgus laxity and ulnar nerve strain. Elbow valgus laxity significantly increased after transection of the UCL. Ulnar nerve length after UCL transection was significantly greater than that in the intact condition at 60° (P = .006) and 90° of elbow flexion (P < .0001). In addition, ulnar nerve strain was positive (increased) at 60° and 90° of elbow flexion. Maximum ulnar nerve strain at 90° of elbow flexion was 3.9% ± 0.9% when the UCL was intact and 6.8% ± 0.7% after transection. UCL transection yielded significant positive correlation between elbow valgus laxity and ulnar nerve strain (P = .006; r = .4714). Increased elbow valgus laxity due to UCL insufficiency may cause elongation of the ulnar nerve and exacerbate cubital tunnel syndrome during the throwing motion.

Does use of the 70° arthroscope improve the outcomes of arthroscopic débridement for chronic recalcitrant tennis elbow?

22-07-2019 – Bong Cheol Kwon, Joon-Kyu Lee, Suk Yoon Lee, Jae-Yeon Hwang

Journal Article

The use of a 70° arthroscope has been reported to provide better visualization of the extensor carpi radialis brevis origin at the lateral epicondyle. We aimed to compare the surgical outcomes of arthroscopic débridement using an additional 70° arthroscope with those using a 30° arthroscope alone in the treatment of chronic recalcitrant tennis elbow. A total of 68 consecutive patients who received arthroscopic débridement for chronic recalcitrant tennis elbow were retrospectively reviewed. A 30° scope was used in 41 patients (mean age, 47 years; range, 26-61 years), whereas an additional 70° scope was used in 27 patients (mean age, 50 years; range, 34-61 years). Outcomes were assessed using a visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire at the preoperative visit and at 3 months, 6 months, and 12 or more months after surgery. Both groups showed significant and progressive improvements in visual analog scale pain scores and Quick Disabilities of the Arm, Shoulder and Hand scores at 3 months, 6 months, and final follow-up (P .05). In addition, the proportions of patients with excellent outcomes and those with clinically meaningful improvements were comparable between the groups (P = .397 and P = .558, respectively). The use of an additional 70° arthroscope did not provide a significant improvement in the outcomes of arthroscopic débridement for chronic recalcitrant tennis elbow.

Long-term follow-up of total shoulder replacement surgery with inset glenoid implants for arthritis with deficient bone

22-04-2019 – Stephen B. Gunther, Sterling K. Tran

Journal Article

Total shoulder replacement surgery has been a successful treatment for patients with shoulder arthritis. However, long-term results are limited by complications such as glenoid loosening, wear, and instability. Also, glenoid bone deficiency limits available treatment options and outcomes. Successful short-term outcomes have been reported previously using inset glenoid implants for deficient arthritic bone, but long-term outcomes have not been reported using this technique. A retrospective analysis was performed on 21 of 24 consecutive patients treated with inset glenoid implants for severe glenohumeral joint arthritis with bone deficiency with prospectively collected data. Inclusion criteria were patients with shoulder arthritis and severe glenoid bone deficiency, defined by perpendicular glenoid vault depth less than 15 mm. No bone grafts were used. All patients were evaluated preoperatively and after surgery with physical examination, radiographic studies, and outcome measures. There were 10 males and 11 females, 17 cases with osteoarthritis and 4 with inflammatory arthritis, and 5 patients with rotator cuff tears (3 full thickness and 2 partial tears). Mean age was 68 years. There were no surgical complications. At a mean follow-up of 8.7 years, there were statistically significant improvements (P < .001) in visual analog pain scores (7.7 to 0.1), American Shoulder and Elbow Surgeons outcome scores (23 to 95), and range of motion. There were no loose glenoids. No patients required any revision surgery. This study documents the long-term efficacy and safety of total shoulder replacement surgery with inset glenoid implants used to reconstruct deficient, arthritic glenoid bone.

Coracohumeral distance and coracoid overlap as predictors of subscapularis and long head of the biceps injuries

25-04-2019 – Maria J. Leite, Márcia C. Sá, Miguel J. Lopes, Rui M. Matos, António N. Sousa, João M. Torres

Journal Article

Subscapularis (SS) lesions are often underdiagnosed because of an incomplete understanding of contributing factors but also because of a greater difficulty in SS tear diagnosis with magnetic resonance imaging or physical examination. In this setting, predicting factors can be useful tools in these injuries’ management. The goal of this study was to determine the influence of the coracohumeral distance (CHD) and coracoid overlap (CO) in anterior rotator cuff lesions, as well as to determine the CHD and CO values that can accurately predict SS and long head of the biceps (LHB) injuries. We performed a retrospective, controlled, single-blinded study. We analyzed 301 patients with rotator cuff pathology and magnetic resonance imaging studies; patients with SS lesions represented the study group. The CHD and CO were measured. We found that lower CHD and higher CO values were progressively related to more serious injuries of the SS and LHB. The CHD was a very strong predictor of SS injury and tear and a good predictor of LHB injuries. A CHD of 7.6 mm had a sensitivity of 84.4% and specificity of 88.6% for SS tears. The CO was also a very strong predictor of SS tears and a good predictor of LHB injury, with a CO of 16.6 mm reaching a sensitivity of 77.8% and specificity of 68.3% for SS tears. The CHD is an excellent predictor of SS tears and a good predictor of LHB lesions, with the CO also being a very strong predictor of SS tears and a good model for LHB injuries.

Letter to the Editor regarding Maillot etxa0al: “Surgical repair of large-to-massive rotator cuff tears seems to be a better option than patch augmentation or débridement and biceps tenotomy: a prospective comparative study”

12-05-2019 – Richard Dimock, A. Ali Narvani


Safe time frame of staged bilateral arthroscopic rotator cuff repair

06-05-2019 – Hwan Jin Kim, Young Moon Kee, Jung Youn Kim, Yong Girl Rhee

Journal Article

Few studies have assessed the outcomes of staged bilateral arthroscopic rotator cuff repair (ARCR). This study aimed to determine the influencing factors related to the outcomes of patients who underwent staged bilateral ARCR and to verify an optimal interval for performing the second rotator cuff repair in staged bilateral ARCR. We analyzed 166 shoulders that underwent staged bilateral ARCR. The average interval between the first- and second-side surgical procedures was 21.9 ± 19.7 months. The minimum follow-up period was 2 years. Clinical outcomes and retear rates were not significantly different according to the order of surgical procedures, sex, arm dominance, age, and tear size (P > .05 for all). The cutoff value for the optimal interval between the first and second surgical procedures for the University of California, Los Angeles score and American Shoulder and Elbow Surgeons score was 9 months, with the area under the curve equal to 0.815 (P < .001) for the University of California, Los Angeles score and 0.806 (P < .001) for the American Shoulder and Elbow Surgeons score. The group with an interval of 9 months or less between the first- and second-side surgical procedures showed significantly inferior clinical outcomes and a higher retear rate (35%) compared with the group with an interval greater than 9 months (retear rate, 10%) (P < .05). Staged bilateral ARCR resulted in significant improvements in clinical outcomes regardless of the order of surgical procedures, sex, arm dominance, age, and tear size. To optimize clinical outcomes of staged bilateral ARCR, second-side surgery should be delayed until 9 months after the first-side surgical procedure.

Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain

08-07-2019 – Rodrigo Py Gonçalves Barreto, Jonathan P. Braman, Paula M. Ludewig, Larissa Pechincha Ribeiro, Paula Rezende Camargo

Journal Article

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms. We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined. Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon’s findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51). Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.

Role of intraoperative navigation in the fixation of the glenoid component in reverse total shoulder arthroplasty: a clinical case-control study

03-07-2019 – Piyush S. Nashikkar, Corey J. Scholes, Mark D. Haber

Journal Article

Fixation of the glenoid baseplate in reverse total shoulder arthroplasty (r
TSA) is an important factor in the success of the procedure. There is limited information available regarding the effect of navigation on fixation characteristics. Therefore, the aims of this study were to determine whether computed tomography-based computer navigation improved the glenoid base plate fixation by (1) increasing the length of screw purchase, (2) altering screw angulation, and (3) decreasing central cage perforation in patients undergoing r
TSA. Patients undergoing r
TSAs using navigation (NAV, N = 27) and manual technique (MAN, N = 23) from January 2014 to July 2017 were analyzed in a case-control design. Screw purchase length and central cage perforation were assessed using multiplanar computed tomography. Median screw purchase length was significantly longer in the NAV group for both anterior (20 mm vs. 15 mm, P < .01) and posterior screws (20 mm vs. 13 mm, P < .01). In addition, the NAV group displayed significantly lower incidences of inadequate screw purchase (<22 mm) for the anterior (64.7% vs. 95.2%, P = .03) and posterior (70.6% vs. 100%, P = .01) screws. Significant differences in axial and coronal screw angulation were observed between groups. Similarly, the NAV group displayed significantly reduced incidence of central cage perforation (17.7% vs. 52.4%, P = .04). The use of computer-assisted navigated r
TSA contributes to significant alterations in screw purchase length, screw angulation, and central cage perforation of the glenoid baseplate compared with non-navigated methods.

Complications after surgical treatment of proximal humerus fractures in the elderly—an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating

06-05-2019 – Alexander Klug, Dennis Wincheringer, Jasmin Harth, Kay Schmidt-Horlohé, Reinhard Hoffmann, Yves Gramlich

Journal Article

To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques. Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted. Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions 4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer’s classification system was not predictive in either group. RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.

Mid- to long-term follow-up of shoulder arthroplasty for primary glenohumeral osteoarthritis in patients aged 60 or under

17-06-2019 – Lionel Neyton, Jacob M. Kirsch, Philippe Collotte, Philippe Collin, Louis Gossing, Mikael Chelli, Gilles Walch

Journal Article

Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy. A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined. A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA. In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.

Management of infected shoulder arthroplasty: a comparison of treatment strategies

19-06-2019 – Matthew Patrick, Heather K. Vincent, Kevin W. Farmer, Joseph J. King, Aimee M. Struk, Thomas W. Wright

Journal Article

The study purpose was to determine whether 2-stage revision procedures result in superior outcomes and whether reverse shoulder arthroplasty produced superior outcomes to hemiarthroplasty or anatomic total shoulder arthroplasty at the time of reimplantation. Our prospectively collected database was retrospectively reviewed for all surgically treated infected shoulder arthroplasties between 2006 and 2014. We included 47 patients in this study: 27 underwent a 2-stage revision, and 20 were treated with an antibiotic spacer as definitive treatment. Preoperative laboratory results, intraoperative cultures and pathology findings, recurrence of infection, complications, and outcome measures were compared between treatment groups. A recurrent infection developed in 3 patients in the antibiotic spacer group and 2 patients in the 2-stage revision group (P = .25). A total of 20 procedure-related complications and 11 medical complications occurred between the 2 groups; however, there was no statistically significant difference between groups. The 2-stage group had statistically significantly better Constant scores (58.1 vs. 33.3, P = .04) and elevation (94.4° vs. 48.6°, P = .02) than the antibiotic spacer group. Subanalysis of the 2-stage revision group showed that reverse total shoulder arthroplasties had statistically superior Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Constant scores; elevation; and abduction compared with hemiarthroplasties or anatomic total shoulder arthroplasties. Two-stage revision procedures and use of an antibiotic spacer for definitive management of periprosthetic shoulder infections appear to be similar and effective in eradicating infections. Two-stage revisions using a reverse total shoulder arthroplasty at the time of reimplantation generate superior range of motion and functional outcome scores.

Aneurysmal bone cysts of the clavicle: a comparison of extended curettage and segmental resection with bone reconstruction

28-04-2019 – Khodamorad Jamshidi, Amin Karimi, Abolfazl Bagherifard, Alireza Mirzaei

Journal Article

Although curettage of an aneurysmal bone cyst (ABC) of the clavicle has a high rate of local recurrence, segmental resection is often avoided for treatment as it causes functional impairment and shoulder deformity. We evaluated the rate of local recurrence and functional outcomes of extended curettage vs. segmental resection with bone reconstruction for the treatment of clavicular ABC. A total of 14 patients with clavicular ABC were studied. Extended curettage and segmental resection with bone reconstruction were done for 6 and 8 patients, respectively. The number of local recurrences and postoperative complications was recorded for each group. The function of the shoulder was assessed using the Constant-Murley score. The mean age of the patients was 26.2 ± 14.7 years (range, 4-56 years). At a mean follow-up of 60 ± 37.6 months, 2 recurrences developed, both in the curettage group. Two postoperative complications (1 infection and 1 nonunion) were also recorded, both in the segmental resection group. The mean Constant-Murley score was 88.2 ± 3.4 in the extended curettage group and 87.3 ± 2.4 in the segmental resection group (P = .85). Considering the comparable function of the shoulder in curettage and segmental resection with bone reconstruction in clavicular ABC, we recommend the latter approach because of the lower recurrence rate, albeit with a higher rate of potential complications.

Tendon stump type on magnetic resonance imaging is a predictive factor for retear after arthroscopic rotator cuff repair

22-07-2019 – Eiichi Ishitani, Nobuya Harada, Yasuo Sonoda, Fumi Okada, Takahiro Yara, Ichiro Katsuki

Journal Article

Fatty infiltration of the rotator cuff musculature increases in larger tears and is a factor in retearing. However, tearing may recur even in patients with small original tears and little fatty infiltration of the rotator cuff musculature. We devised a system to classify the rotator cuff tendon stump by magnetic resonance imaging (MRI) signal intensity and investigated prognosis-related factors associated with retear based on other MRI findings. We analyzed and compared the signal intensity of the rotator cuff tendon stump and deltoid on preoperative T2-weighted fat-suppressed MRI in 305 patients who underwent primary arthroscopic rotator cuff repair. We also investigated the tear size, Goutallier stage, and global fatty degeneration index. In a type 1 stump, the tendon stump had a lower (darker) signal intensity than the deltoid. In type 2, the signal intensities of the tendon stump and deltoid were equivalent. In type 3, the signal intensity of the tendon stump was higher (whiter) than that of the deltoid. Multiple regression analysis of the association between retear and other parameters identified stump type (odds ratio [OR], 4.28), global fatty degeneration index (OR, 2.99), and anteroposterior tear size (OR, 1.06) as significant factors. The retear rates were 3.4% for type 1 stumps, 4.9% for type 2, and 17.7% for type 3. Type 3 stumps had a significantly higher retear rate, suggesting that stump signal intensity may be an important indicator for assessing the stump’s condition. Our stump classification may be useful in choosing suture techniques and postoperative therapies.

Does arthroscopic preemptive extensive rotator interval release reduce postoperative stiffness after arthroscopic rotator cuff repair?: a prospective randomized clinical trial

22-07-2019 – Jong-Ho Kim, Dae-Ho Ha, Seung-Min Kim, Ki-Won Kim, Sang-Yup Han, Yang-Soo Kim

Journal Article

To investigate whether preemptive extensive rotator interval (RI) release during arthroscopic rotator cuff repair (ARCR) would reduce postoperative stiffness. From July 2015 to September 2016, a total of 80 patients who were scheduled for ARCR were enrolled and randomly allocated into 2 groups: the preemptive extensive RI release group (group 1, n=40) and the RI nonrelease group (group 2, n=40). The American Shoulder and Elbow Surgeons scale, Constant score, Korean Shoulder Scale (KSS), visual analog scale (VAS) pain score, and range of motion (ROM) were evaluated before surgery; 3, 6, and 12 months after surgery; and at last follow-up. Magnetic resonance imaging was performed at postoperative 12 months. The mean follow-up period was 26.5 months. The functional and pain scores in both groups were significantly improved at the last follow-up (P < .05). Group 1 showed a significantly higher sum of ROM with a difference of 27° and 1.6 vertebral level of internal rotation compared to group 2 at postoperative 3 months (P < .05). Constant score and KSS were significantly higher in group 1 than in group 2 at this time point (P .05). The retear rate and pathologic change of the long head of the biceps tendon during follow-up were not significantly different between the 2 groups (P > .05). Arthroscopic preemptive extensive RI release can reduce early postoperative shoulder stiffness after ARCR but does not significantly change the overall clinical outcome after surgery.

Letter to the editor regarding Milchteim etxa0al: “Subacromial dislocation of the acromioclavicular joint with associated fracture of the clavicle”

06-05-2019 – James A. Fagg, Emma J. Davies, David Stanley


Congenital pseudarthrosis of the clavicle: surgical decision making and outcomes

21-08-2019 – Arin E. Kim, Carley B. Vuillermin, Donald S. Bae, Julie B. Samora, Peter M. Waters, Andrea S. Bauer

Journal Article

Congenital pseudarthrosis of the clavicle (CPC) is a rare entity in which the primary ossification center of the clavicle fails to coalesce. The natural history of CPC is unknown, and there is controversy regarding surgical vs. conservative treatment. A retrospective review of 47 pediatric patients treated for CPC was performed. The Quick Disabilities of the Arm and Shoulder (Quick
DASH) survey and the Patient Reported Outcomes Measurement Information System (PROMIS) upper extremity domain were used to assess overall patient satisfaction, function, and quality of life after treatment. Twenty-four of 47 (51%) patients underwent surgical treatment. Of these, 9 patients (38%, 9/24) underwent surgery at <18 months of age using suture fixation alone, whereas the older 15 surgical patients (15/24, 62%) were treated with plate fixation. The younger surgical cohort had a nonunion rate of 43% (3/7) compared with 13% (2/15) in the older cohort. All surgical patients had resolution of preoperative symptoms. Eleven (11/24, 46%) surgical subjects responded to the follow-up survey. Upper extremity function normalized according to the Quick
DASH survey (score of 0 for all subjects). The median PROMIS upper extremity domain score was 55, which was also in the normal range. This series of CPC patients improves our understanding of treatment options and outcomes of surgical treatment. All surgical patients had resolution of preoperative symptoms. Patients treated surgically with stable fixation at an older age had higher rates of union than those treated in infancy with suture fixation. Patient-reported outcomes were favorable overall.

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

Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty

21-08-2019 – Myung Seo Kim, Ho Yeon Jeong, Jong Dae Kim, Kyung Han Ro, Sung-Min Rhee, Yong Girl Rhee

Journal Article

Reverse total shoulder arthroplasty (RSA) is a widely accepted treatment for irreparable massive rotator cuff tear (m
RCT) and cuff tear arthropathy (CTA), but its impact on activities of daily living (ADLs) remains unclear. We retrospectively analyzed 77 patients (age range, 54-87 years; follow-up range, 36.1-120.3 months) with irreparable m
RCT and CTA treated by medialized RSA between 2008 and 2015. Ten activities considered essential for daily living were selected and scored from 0 to 3. The mean visual analog scale scores during motion and University of California at Los Angeles and Constant scores significantly improved at final follow-up (all P < .001). Active forward flexion, external rotation at the side, and internal rotation to the posterior (IRp) were 92.5%, 79.6%, and 48.4% of the contralateral side, respectively, at final follow-up. Active forward flexion and external rotation at the side recovered within 6 months after surgery, similar to the level at final follow-up, but IRp did not reach the preoperative status until final follow-up. ADLs with mean scores of less than 2.0 at final follow-up were "wash the opposite shoulder," "wash the opposite axilla," "use a back pocket," "manage the toilet," and "wash the back" (only 36.4% of patients were able to wash their back at final follow-up). RSA for irreparable m
RCT and CTA showed satisfactory clinical outcomes. However, IRp was associated with a limited range compared with the other shoulder motions; therefore, all ADLs associated with internal rotation demonstrated lower recovery rates than expected.

The effect of patient-reported metal allergies on the outcomes of shoulder arthroplasty

21-08-2019 – Justin C. Kennon, Julia Lee, Chad Songy, Dave Shukla, Robert H. Cofield, Joaquin Sanchez-Sotelo, John W. Sperling

Journal Article

Although literature exists regarding hip and knee arthroplasty outcomes in patients with skin allergy to metals, there is minimal information about skin allergy implications on shoulder arthroplasty outcomes. The purpose of this study was to determine the results, complications, and failure rate among patients with a self-reported metal allergy undergoing shoulder arthroplasty. Fifty-two shoulder arthroplasties were performed at our Institution in 43 patients with self-reported metal allergies. Forty primary and 12 revision shoulder arthroplasties were performed using anatomic (30) and reverse (22) components. Retrospective chart review was performed to determine metal allergy history, implant composition, pain, motion, and complications. Radiographs were reviewed to determine mechanical failure rates. Average follow-up time was 65 months. Allergies reported included nickel (37), cobalt chrome (4), copper (2), zinc (1), titanium (1), gold (1), and nonspecific metal allergy (8); 8 patients reported multiple metal allergies. All components implanted in patients with nickel allergies contained nickel. At most recent follow-up, pain was rated as none or mild in 88% of shoulders. Active elevation improved from 80° to 141° and external rotation from 24° to 52°. Two revisions were performed for glenoid loosening (3.8%); both were revision cases with substantial glenoid bone loss. One patient with mild pain had a radiographically loose glenoid component 12 years after anatomic shoulder arthroplasty. Results from this study suggest that shoulder arthroplasty in patients with self-reported metal allergy provides satisfactory pain relief and improved range of motion with low revision rates.

The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty

21-08-2019 – Jordan D. Walters, L. Watson George, Ryan N. Walsh, Jim Y. Wan, Tyler J. Brolin, Frederick M. Azar, Thomas W. Throckmorton

Journal Article

The purpose of this study was to determine the influence of current and former tobacco use on minimum 2-year clinical and radiographic outcomes after reverse total shoulder arthroplasty (RTSA). Review of primary RTSA patient data identified 186 patients with at least 2 years of follow-up. Patients were classified as nonsmokers (76 patients), former smokers (89 patients), or current smokers (21 patients). Assessment included preoperative and postoperative visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, strength, range of motion, complications, revisions, and narcotic use. Radiographs were analyzed for signs of loosening or mechanical failure. Overall mean age of the patients was 70 (48-87) years, and mean follow-up was 2.6 (2.0-5.7) years. Smokers (62.1 years) were significantly younger than nonsmokers (70.7 years) and former smokers (70.8 years; P = .00002). All patients had significant improvements in pain, American Shoulder and Elbow Surgeons score, strength, and forward flexion range of motion; however, smokers had higher visual analog scale pain scores (mean, 2.5) than nonsmokers (mean, 1.8) or former smokers (mean, 1.0; P = .014). Otherwise, no differences were found regarding any of the postoperative parameters (P > .05). Aside from increased patient-reported pain, current tobacco use does not appear to negatively affect outcomes after primary RTSA. The RTSA design obviates the need for a functioning rotator cuff, possibly mitigating tobacco’s negative effects previously demonstrated in rotator cuff repair and anatomic total shoulder arthroplasty. Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA.

Posterior shoulder tightness can be a risk factor of scapular malposition: a cadaveric biomechanical study

20-08-2019 – Teruhisa Mihata, Michelle H. McGarry, Masaki Akeda, Alexander B. Peterson, Ross C. Hunter, Lauren Nguyen, Masashi Neo, Thay Q. Lee

Journal Article

Scapular malposition and posterior shoulder tightness are key pathologic processes in the shoulder of throwing athletes. The objective of this study was to investigate the effects of posterior capsule tightness, posterior rotator cuff muscle tightness, or both on scapular position. Ten shoulders from 5 fresh frozen cadaveric male torsos were tested in maximum internal, neutral, and maximum external shoulder rotations at 0°, 45°, and 90° of shoulder abduction. Scapular rotation-namely, upward and downward rotation, internal and external rotation, and anterior and posterior tilt-and the scapula-spine distance were measured by using a Micro
Scribe digitizer (Revware, Raleigh, NC, USA). Each shoulder underwent 4 experimental stages: intact; isolated posterior rotator cuff muscle (infraspinatus and teres minor) tightness; both posterior rotator cuff muscle and capsule tightness; and isolated posterior capsule tightness. Posterior muscle tightness significantly decreased upward rotation (P< .05) only in maximum shoulder internal rotation at 45° or 90° of shoulder abduction, whereas posterior capsule tightness did not affect upward rotation (P= .09 to .96). Posterior capsule tightness significantly increased scapular internal rotation (P< .01), but posterior muscle tightness did not change scapular internal rotation (P= .62 to .89). Posterior capsule tightness significantly increased both the superior and inferior scapula-spine distance (ie, caused scapular protraction) in maximum shoulder external rotation at 90° of abduction (P< .01). Posterior shoulder tightness resulted in scapular malposition. However, the muscular and capsular components of that tightness affected the scapular position differently. For the treatment of scapula malposition, stretching of the posterior shoulder capsule and muscles is recommended.

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.

PROMIS CAT forms demonstrate responsiveness in patients following arthroscopic rotator cuff repair across numerous health domains

20-08-2019 – Felicity Fisk, Sreten Franovic, Joseph S. Tramer, Caleb Gulledge, Noah A. Kuhlmann, Chaoyang Chen, Vasilios Moutzouros, Stephanie Muh, Eric C. Makhni

Journal Article

Recent studies of patients with rotator cuff tears have demonstrated improved efficiency with Patient-Reported Outcomes Measurement Information System (PROMIS) when compared with traditional patient-reported outcome measures (PROM). However, these studies have been cross-sectional in nature and the responsiveness of PROMIS computer adaptive test (CAT) forms has not been evaluated. The purpose of this study was to determine the responsiveness of PROMIS CAT assessments in patients undergoing arthroscopic rotator cuff repair. All patients undergoing arthroscopic rotator cuff repair by one of 3 fellowship-trained surgeons were included in the study. PROMIS CAT upper extremity physical function (“PROMIS-UE”), pain interference (“PROMIS-PI”), and depression (“PROMIS-D”) scores from preoperative and 6-month postoperative visits were collected and analyzed. Patient-centric demographic factors, tear size, and biceps involvement were also correlated to preoperative and postoperative PROMIS scores. A total of 101 patients were enrolled in the study. The average age was 59.8 ± 8.9 years with 51 males (50.5%). Preoperative PROMIS-UE, PROMIS-PI, and PROMIS-D CAT scores improved significantly from 29.8 ± 6.0, 62.6 ± 5.1, and 48.4 ± 8.7, respectively, to 40.9 ± 9.8, 51.2 ± 9.3, and 42.9 ± 9.0, respectively, at 6-month follow-up (P < .001). Preoperative correlations were found between PROMIS-UE and PROMIS-PI scores (P < .001) and between PROMIS-PI and PROMIS-D scores (P = .001). No significant correlation was found between PROMIS-UE and PROMIS-D scores (P = .08), preoperatively. Preoperative PROMIS-UE, PROMIS-PI, or PROMIS-D scores were not correlated with rotator cuff tear size (P = .4). PROMIS CAT forms demonstrate responsiveness in patients undergoing arthroscopic rotator cuff repair across numerous domains.

The fragility of findings of randomized controlled trials in shoulder and elbow surgery

20-08-2019 – Joseph J. Ruzbarsky, Ryan C. Rauck, Joseph Manzi, Sariah Khormaee, Bridget Jivanelli, Russell F. Warren

Journal Article

Considered the gold standard of study designs, randomized controlled trials’ (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery. A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold. Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis. The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.

Relation between preoperative electromyographic activity of the deltoid and upper trapezius muscle and clinical results in patients treated with reverse shoulder arthroplasty

20-08-2019 – HongRi Li, Seung-hyun Yoon, Doohyung Lee, Heewoong Chung

Journal Article

If patients susceptible to poor clinical outcomes could be predicted before reverse shoulder arthroplasty (RSA), it would help to set reasonable postsurgical patient expectations in the preoperative setting. Our hypothesis was that the preoperative electromyographic (EMG) activity of the deltoid and upper trapezius muscles would be correlated with clinical outcomes of patients undergoing RSA. EMG activity of the deltoid and upper trapezius muscles was measured in 25 patients scheduled to undergo RSA during 3 motions: shrugging, forward flexion, and abduction. Their postoperative clinical results were assessed prospectively during regular outpatient visits, including strength, active range of motion (ROM), pain, and functional scores. The correlations between the preoperative EMG activities and clinical results were analyzed. Postoperative shoulder strength after RSA was increased in patients with greater preoperative EMG activity of the middle deltoid and upper trapezius. Preoperative EMG activity of the anterior or middle deltoid muscle was associated with active ROM in flexion or abduction, whereas EMG activity of the posterior deltoid was associated with active ROM in external rotation. Shoulder strength after RSA was positively correlated with preoperative EMG activity of the deltoid and upper trapezius. Active ROM after RSA was positively correlated with preoperative EMG activity of the deltoid. Therefore, preoperative EMG measurements of the deltoid and upper trapezius may predict clinical outcomes after RSA.

Exercise therapy may affect scapular position and motion in individuals with scapular dyskinesis: a systematic review of clinical trials

20-08-2019 – Afsun Nodehi Moghadam, Leila Rahnama, Shohreh Noorizadeh Dehkordi, Shima Abdollahi

Journal Article, Review

Therapeutic exercise for scapular muscles is suggested to be effective in reducing shoulder pain in patients with rotator cuff disorders, whereas its effectiveness on scapular position and motion has remained unclear. Therefore, the aim of this systematic review was to investigate whether exercise therapy improves scapular position and motion in individuals with scapular dyskinesis. This study is a wide systematic review including any type of clinical trial in which the effect of any type of therapeutic exercise, including scapular muscle strengthening, stretching, and scapular stabilization exercise, is investigated in adult participants. Twenty studies were included in this systematic review. Studies were categorized on the basis of the techniques they used to measure scapular position and motion and the included participants. Methodologic quality of the studies was assessed by the Cochrane tool of assessing the risk of bias. Eight studies used 3-dimensional techniques for measuring scapular motions. Among them, 5 studies showed significant effects of exercise on scapular motion, of which 3 studies investigated individuals with subacromial impingement syndrome (SIS). The other 12 studies used 2-dimensional measurement techniques, of which 8 studies reported significant effects of exercise on scapular position and motion both in SIS patients and in asymptomatic individuals. However, their methodologic quality was debatable. Therefore, there was conflicting evidence for the effect of exercise on scapular dyskinesis. There is a lack of evidence for beneficial effects of exercise in improving scapular position and motion in individuals with scapular dyskinesis. However, exercise is beneficial in reducing pain and disability in individuals with SIS.

Subscapularis structural integrity and function after arthroscopic Latarjet procedure at a minimum 2-year follow-up

15-08-2019 – María Valencia, Gloria Fernández-Bermejo, María D. Martín-Ríos, Javier Fernández-Jara, Diana Morcillo-Barrenechea, Ismael Coifman-Lucena, Antonio M. Foruria, Emilio Calvo

Journal Article

Subscapularis function after arthroscopic Bankart repair has been widely studied. However, data regarding subscapularis performance after arthroscopic Latarjet procedures are lacking. This study aimed to evaluate subscapularis clinical and radiologic performance after arthroscopic Latarjet procedures. We included 40 patients who underwent arthroscopic Latarjet procedure with a minimum 2-year follow-up. Clinical evaluation included Western Ontario Shoulder Instability Index and Rowe scores, specific subscapularis isokinetic study, and lift-off tests. Contralateral measurements were used for comparison. Computed tomographic evaluation included graft consolidation, muscle dimensions, and degree of fatty atrophy, calculated as the mean muscle attenuation (MMA). There was a decrease of 8.3% of maximum internal rotation peak torque in the operated arm (P = .02). However, there was no significant difference in the agonist-antagonist ratio: 76.9% in the operated arm and 76% in the contralateral (P = .82). Lift-off strength test demonstrated a decrease in the first year but not at final follow-up (P = .38). There was a significant decrease in lift-off distance of 23% compared to the contralateral side (P < .001). Subscapularis MMA was diminished when compared to the infraspinatus/teres minor (P < .001) at the expense of its upper part (P = .03). Hyperlaxity and number of dislocation episodes were correlated to a lower MMA (P = .046 and P = .005). Arthroscopic Latarjet procedures provide satisfactory clinical results. There seems to be a diminished subscapularis MMA depending on its superior half. Hyperlaxity and number of previous dislocations were correlated to a lower MMA. Although there was a decrease in the maximum internal rotation peak torque, we did not find any difference in the agonist-antagonist ratio or in the final lift-off strength between sides.

Effect of different trunk postures on scapular muscle activities and kinematics during shoulder external rotation

15-08-2019 – Kosuke Miyakoshi, Jun Umehara, Tomohito Komamura, Yasuyuki Ueda, Toru Tamezawa, Gakuto Kitamura, Noriaki Ichihashi

Journal Article

Shoulder external rotation at abduction (ER) is a notable motion in overhead sports because it could cause strong stress to the elbow and shoulder joint. However, no study has comprehensively investigated the effect of different trunk postures during ER. This study aimed to investigate the effect of different trunk postures on scapular kinematics and muscle activities during ER. Fourteen healthy men performed active shoulder external rotation at 90° of abduction with the dominant arm in 15 trunk postures. At maximum shoulder external rotation in 15 trunk postures, including 4 flexion-extension, 6 trunk rotation, and 4 trunk side-bending postures, as well as upright posture as a control, scapular muscle activities and kinematics were recorded using surface electromyography and an electromagnetic tracking device, respectively. The data obtained in the flexion-extension, trunk rotation, and trunk side-bending postures were compared with those obtained in the upright posture. In the flexion-extension condition, scapular posterior tilt and external rotation significantly decreased, but the muscle activities of the lower trapezius and infraspinatus significantly increased in maximum trunk flexion. Moreover, scapular upward rotation and the activity of the serratus anterior significantly increased in maximum trunk extension. In the rotation condition, scapular posterior tilt and external rotation significantly decreased, but the activity of the serratus anterior significantly increased in the maximum contralateral trunk rotation posture. In the trunk side-bending condition, scapular posterior tilt and the external rotation angle significantly decreased. Trunk postures affected scapular kinematics and muscle activities during ER. Our results suggest that different trunk postures activate the lower trapezius and serratus anterior, which induce scapular posterior tilt.

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.

Evaluation of cerebral oxygen perfusion during shoulder arthroplasty performed in the semi–beach chair position

14-08-2019 – Justin H. Chan, Hector Perez, Harrison Lee, Matthew Saltzman, Guido Marra

Journal Article

The beach chair position is commonly used when performing shoulder arthroplasty. However, this position has been associated with hypotension, potentially leading to cerebral hypoperfusion, which may cause neurologic injury. In addition, shoulder arthroplasty cases are associated with longer operative times, posing a potentially greater risk of cerebral hypoperfusion. We aim to evaluate the risk of cerebral desaturation events (CDEs) during the course of total shoulder arthroplasty. Twenty-six patients undergoing shoulder arthroplasties were monitored for changes in cerebral perfusion. Seven specific time-points during the procedure were labeled for comparison of events: baseline, beach chair, incision, humeral broaching, glenoid reaming, glenoid component implantation, and humeral component implantation. Cerebral oxygen perfusion was measured using near-infrared spectroscopy. A CDE was described as a decrease of oxygen saturation greater than 20%. Nineteeen of 25 subjects experienced a CDE. 42% of these patients experienced CDEs during semi-beach chair positioning. Patients experienced the largest oxygen saturation drop during semi-beach chair positioning. Transition from baseline to semi-beach chair was the only event to have a statistically significant decrease in cerebral perfusion (8%, P < .05). There was a statistically significant percentage change in mean oxygen saturation in the semi-beach chair interval (10%, P < .01) and the semi-beach chair to incision interval (7%, P < .01). Most patients experienced an intraoperative CDE, with greatest incidence during semi-beach chair positioning. The largest decline in cerebral oxygen saturation occurred during semi-beach chair positioning. Implant implantation was not associated with decrease in cerebral oximetry.

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.

Application of a new polyester patch in arthroscopic massive rotator cuff repair—a prospective cohort study

14-08-2019 – Daniel Smolen, Nicolas Haffner, Rainer Mittermayr, Florian Hess, Christoph Sternberg, Jan Leuzinger

Journal Article

Massive rotator cuff (RC) tears still present a clinically challenging problem, with reported rerupture rates in up to 94%. The study objective was to determine the impact of synthetic patch augmentation for massive RC tears. Between June 2012 and 2014, we performed 50 arthroscopic RC reconstructions augmented with a synthetic polyester patch. Pre- and postoperative imaging methods included arthrographic magnetic resonance imaging, arthrographic computed tomography, and ultrasound examination to determine tendon integrity or rerupture. Clinical outcome was evaluated using the Constant-Murley score and the subjective shoulder value. Mean clinical midterm and final follow-up was 22 months (9-35 months) and 52 months (25-74 months), respectively. The mean Constant-Murley score increased significantly from 36.5 (±16.4 standard deviation [SD]) preoperatively to a midterm value of 81.2 (±9.6 SD; P < .0001) and further improved to a mean of 83.4 (±10.8 SD) at final follow-up. The mean subjective shoulder value increased from 40.3 (±24.3 SD) to 89.2 (±12.9 SD; P < .0001) at midterm and to 89.6 (±15.2 SD) at final follow-up. We observed 7 complete reruptures (14%). However, reruptures did not correlate with revision surgery, which was performed in 8 patients. The main reason for revision was frozen shoulder or arthrofibrosis with an intact reconstruction and patch, which was performed in 6 cases. The retear rate of 14% compared favorably with nonaugmented RC repairs in the literature. Therefore, we conclude that patch augmentation in massive RC tears is feasible to reduce retears and to improve clinical outcome.

Glenoid bone grafting in primary reverse total shoulder arthroplasty: a systematic review

14-08-2019 – Ryan A. Paul, Naomi Maldonado-Rodriguez, Shgufta Docter, Moin Khan, Christian Veillette, Nikhil Verma, Gregory Nicholson, Timothy Leroux

Journal Article, Review

Reverse total shoulder arthroplasty (RSA) with glenoid bone grafting has become a common option for management of glenoid bone loss associated with glenohumeral osteoarthritis. The objectives of this review were to determine (1) the rate of graft union, (2) the revision and complication rates, and (3) functional outcomes following primary RSA with glenoid bone grafting. A comprehensive search of the MEDLINE, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was completed for studies reporting clinical outcomes following primary RSA with glenoid bone grafting. Pooled and frequency-weighted means were calculated where applicable. Overall, 11 studies and 393 patients were included in the study. The mean patient age was 73 ± 2.2 years, and the mean follow-up period was 34 ± 10 months. The overall graft union rate was 95%, but the rate was 97% among cases using autograft bone (8 studies, n = 254). When stratified by technique, concentric bone grafts had a 100% union rate (4 studies, n = 139). Conversely, eccentric grafts had an overall union rate of 92% (7 studies, n = 240), which improved to 94% when using autograft bone (4 studies, n = 115). At final follow-up, the revision rate was 2%, the complication rate was 18%, and there was consistent improvement in range of motion and functional outcome scores. Glenoid bone grafting during primary RSA results in excellent early-term clinical outcomes, low complication and revision rates, and high rates of graft union.

Clinical results of bony increased-offset reverse shoulder arthroplasty (BIO-RSA) associated with an onlay 145° curved stem in patients with cuff tear arthropathy: a comparative study

12-08-2019 – Edoardo Franceschetti, Riccardo Ranieri, Edoardo Giovanetti de Sanctis, Alessio Palumbo, Francesco Franceschi

Journal Article

The main limits of the Grammont design reverse shoulder arthroplasty (RSA) are loss of external rotation and scapular notching. They can be addressed with glenoid or humeral lateralization. The aim of the study was to compare outcomes of lateralized bony increased-offset RSA (BIO-RSA) vs. standard RSA in patients with an onlay 145° curved stem. A comparative cohort study of 29 standard RSAs and 30 BIO-RSAs was performed. At 2 years postoperatively, Constant score, American Shoulder and Elbow Surgeons score, visual analog scale score, range of motion, and radiographs were evaluated. After comparison between the groups, patients were analyzed considering patients younger and older than 65 years. All parameters significantly improved after surgery in both groups. Postoperatively, the 2 groups did not show any clinical and radiographic differences (P > .05). In patients .05). In patients >65 years, standard technique showed a positive trend for all the parameters (P > .05). No other significant differences were found. At 2 years of follow-up, the use of standard RSA or BIO-RSA in an implant with an onlay 145° curved stem provided similar outcomes. The humeral lateralization alone is sufficient to decrease notching and to improve external rotation. BIO-RSA increases external rotation in patients between 50 and 65 years old. Glenoid bone graft in RSA has a high incorporation rate (completed in 90%).

A prospective study comparing tendon-to-bone interface healing using an interposition bioresorbable scaffold with a vented anchor for primary rotator cuff repair in sheep

12-08-2019 – Jeremiah Easley, Christian Puttlitz, Eileen Hackett, Cecily Broomfield, Lucas Nakamura, Michael Hawes, Charles Getz, Mark Frankle, Patrick St. Pierre, Robert Tashjian, P. Dean Cummings, Joseph Abboud, Derek Harper, Kirk McGilvray

Journal Article

The purpose of this study was to evaluate the biomechanical and histologic properties of rotator cuff repairs using a vented anchor attached to a bioresorbable interpositional scaffold composed of aligned PLGA (poly(l-lactide-co-glycoside)) microfibers in an animal model compared to standard anchors in an ovine model. Fifty-six (n = 56) skeletally mature sheep were randomly assigned to a repair of an acute infraspinatus tendon detachment using a innovative anchor-PLGA scaffold device (Treatment) or a similar anchor without the scaffold (Control). Animals were humanely euthanized at 7 and 12 weeks post repair. Histologic and biomechanical properties of the repairs were evaluated and compared. The Treatment group had a significantly higher fibroblast count at 7 weeks compared to the Control group. The tendon bone repair distance, percentage perpendicular fibers, new bone formation at the tendon-bone interface, and collagen type III deposition was significantly greater for the Treatment group compared with the Control group at 12 weeks (P ≤ .05). A positive correlation was identified in the Treatment group between increased failure loads at 12 weeks and the following parameters: tendon-bone integration, new bone formation, and collagen type III. No statistically significant differences in biomechanical properties were identified between Treatment and Control Groups (P > .05). Use of a vented anchor attached to a bioresorbable interpositional scaffold composed of aligned PLGA microfibers improves the histologic properties of rotator cuff repairs in a sheep model. Improved histology was correlated with improved final construct strength at the 12-week time point.

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.

Three-dimensional in vivo scapular kinematics and scapulohumeral rhythm: a comparison between active and passive motion

12-08-2019 – Bonggun Lee, Doosup Kim, Younghwan Jang, Hanbin Jin

Journal Article

The aim of this study was to compare the scapular kinematics and scapulohumeral rhythm of healthy participants during arm elevation and lowering and to find the difference between active motion and passive motion of the shoulder. The study examined the shoulders of 10 healthy men (mean age, 23.5 years; age range, 22-28 years). The shoulders of participants were elevated and lowered while fluoroscopic images were taken, and 3-dimensional bone models were created from 2-dimensional to 3-dimensional images using model registration techniques. The Euler angle sequences of the models’ scapular kinematics and scapulohumeral rhythm were compared during active and passive shoulder motion. There was a significant statistical difference of upward rotation during arm elevation between active and passive shoulder movements (P = .027). In particular, the upward rotation between 45° and 90° of elevation showed a statistically significant difference (P < .001). When the scapula was tilted posteriorly by active motion, it resulted in a statistically significant difference as there was more tilting in the high-degree range of motions than when it was tilted by passive motion (P < .001). There was no statistically significant difference between the 2 groups in scapular external rotation. However, during arm lowering, scapular kinematics did not show statistically significant difference between active and passive motion. The scapular kinematics showed statistically significant differences between active and passive motion of upward rotation and posterior tilting of the scapula during arm elevation, but there were none during lowering. In terms of upward rotation, active shoulders rotated more upward during arm elevation.

Shoulder arthroplasty in patients with immunosuppression following solid organ transplantation

12-08-2019 – Taku Hatta, Joseph M. Statz, Eiji Itoi, Robert H. Cofield, John W. Sperling, Mark E. Morrey

Journal Article

The purpose was to determine the risk and outcomes of primary shoulder arthroplasties in patients with immunosuppression who had undergone solid organ transplantation. Using a single institution’s total joint registry, we reviewed 30 primary shoulder arthroplasties in 25 post-transplantation patients, including 12 total shoulder arthroplasties, 10 hemiarthroplasties, and 8 reverse shoulder arthroplasties, between 1985 and 2012. Therapy and patient variables were recorded, including immunosuppressive therapy protocols, the date of preceding solid organ transplantation, and specific medications taken in the perioperative period. We matched a cohort of control patients for age, sex, type of implant, and year of surgery at a ratio of 4:1. Two groups were compared regarding mortality risk, complications, and clinical outcomes (pain score, range of motion, and American Shoulder and Elbow Surgeons score). No periprosthetic infections occurred in the post-transplantation group at a mean follow-up of 39 months. However, the post-transplantation group showed an increased risk of periprosthetic fractures compared with the control group (hazard ratio, 8.18; 95% confidence interval, 1.22-70.98; P = .03). Despite the increase in fractures, the overall number of complications did not differ between the groups. Furthermore, postoperative shoulder function and outcome scores were not significantly different between patients who had a prior transplant and those who did not. Primary shoulder arthroplasty in patients with immunosuppression who underwent solid organ transplantation is a successful procedure to treat glenohumeral arthritis. In contrast, there may be an increased risk of periprosthetic fractures in patients with a history of a solid organ transplant.

Single Assessment Numeric Evaluation scores correlate positively with American Shoulder and Elbow Surgeons scores postoperatively in patients undergoing rotator cuff repair

12-08-2019 – Julia S. Retzky, Matthew Baker, Casey V. Hannan, Uma Srikumaran

Journal Article

The American Shoulder and Elbow Surgeons (ASES) shoulder score and the Single Assessment Numeric Evaluation (SANE) measure shoulder function. Relative to the ASES questionnaire, the SANE questionnaire is shorter and easier to score. We sought to determine (1) the correlation between ASES and SANE scores preoperatively and at 2 years postoperatively in patients undergoing rotator cuff repair (RCR) or shoulder arthroplasty and (2) the correlation between the change in ASES scores and change in SANE scores. We reviewed the records of 107 patients who underwent RCR (n = 74) or shoulder arthroplasty (n = 33), which included patients undergoing total shoulder arthroplasty (n = 18) and reverse total shoulder arthroplasty (n = 15), at our institution from 2014 to 2015 and who completed the ASES and SANE questionnaires preoperatively and at least 2 years postoperatively. Pearson correlation coefficients were calculated to determine the relationship between SANE and ASES scores in RCR patients and arthroplasty patients (both total shoulder arthroplasty and reverse total shoulder arthroplasty) at each time point. In the RCR group, correlations between SANE and ASES scores were moderately positive preoperatively (r = 0.30) and strongly positive postoperatively (r = 0.86). In the arthroplasty group, correlations between SANE and ASES scores were moderately positive preoperatively (r = 0.46) and strongly positive postoperatively (r = 0.78). SANE scores correlate positively with ASES scores postoperatively in patients undergoing RCR. Therefore, SANE scores, together with clinician-based and combination scores, can be used to assess postoperative shoulder function in these patients.

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.

Predictors of failure after conservative treatment of symptomatic partial-thickness rotator cuff tear

11-08-2019 – Morteza Nakhaei Amroodi, Mostafa Salariyeh

Journal Article

Further studies are required to determine the effectiveness of conservative treatment of partial-thickness rotator cuff tear (PTRCT). Here, we aim to identify the predictors of failure after conservative treatment in a large series of patients with symptomatic PTRCT. The outcome of conservative treatment in a retrospective cohort of 272 patients with symptomatic PTRCT was evaluated. Demographic, clinical, and radiographic characteristics were extracted from the patients’ medical records. Subjective assessments included Constant Shoulder Score (CSS), visual analog scale for pain (VAS pain), activities of daily living (ADL) score, and American Shoulder and Elbow Surgeons (ASES) score, all performed at the first visit. The association of treatment failure with the patient/tear characteristics was assessed. The bursal-type PTRCT was associated with male gender (P = .02), earlier referral of the patients (P = .001), more nonsteroidal anti-inflammatory drug consumption (P = .004), more positive painful arc syndrome (P = .006), and lower CSS (P < .001). These symptoms subsided completely or considerably in 172 (63.2%) patients after the conservative treatment, from which the disease relapsed in 21 (12.2%) patients at the mean follow-up of 22.2 ± 8.8 months. The symptoms led to surgery in the remaining 100 (36.8%) patients. The failure rate of conservative treatment was significantly higher in the dominant injuries (P = .015), the bursal type (P < .001), and tears involving more than 50% of the depth of the tendon (P 50% of the tendon depth are factors capable of predicting failure after conservative management of PTRCT.

Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty

07-08-2019 – Anirudh K. Gowd, Avinesh Agarwalla, Nirav H. Amin, Anthony A. Romeo, Gregory P. Nicholson, Nikhil N. Verma, Joseph N. Liu

Journal Article

We aimed to demonstrate that supervised machine learning (ML) models can better predict postoperative complications after total shoulder arthroplasty (TSA) than comorbidity indices. The American College of Surgeons-National Surgical Quality Improvement Program database was queried from 2005-2017 for TSA cases. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, extended length of stay (>3 days), surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, and readmission. Each SML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and the positive predictive value (PPV) of complications. We identified a total of 17,119 TSA cases. Mean age, BMI, and length of stay were 69.5 ± 9.6 years, 31.1 ± 6.8, and 2.0 ± 2.2 days. Percentage hematocrit, BMI, and operative time were of highest importance in outcome prediction. SML algorithms outperformed ASA classification models for predicting any adverse event (71.0% vs. 63.0%), transfusion (77.0% vs. 64.0%), extended length of stay (68.0% vs. 60.0%), surgical site infection (65.0% vs. 58.0%), return to the operating room (59.0% vs. 54.0%), and readmission (64.0% vs. 58.0%). SML algorithms demonstrated the greatest PPV for any adverse event (62.5%), extended length of stay (61.4%), transfusion (52.2%), and readmission (10.1%). ASA classification had a 0.0% PPV for complications. With continued validation, intelligent models could calculate patient-specific risk for complications to adjust perioperative care and site of surgery.

Biomechanical analysis of latissimus dorsi tendon transfer with and without superior capsule reconstruction using dermal allograft

29-04-2019 – Reza Omid, Michael A. Stone, Charles C. Lin, Nilay A. Patel, Yasuo Itami, Michelle H. McGarry, Thay Q. Lee

Journal Article

Irreparable rotator cuff tears (ICTs) remain a challenging treatment dilemma. Superior capsule reconstruction (SCR) acts as a static stabilizer to decrease superior humeral head migration. Latissimus dorsi tendon transfers (LDTs) dynamically decrease superior humeral head migration and improve external rotation. We hypothesized that the dynamic stabilizing effect of the latissimus transfer plus the static stabilizing effect of SCR would improve shoulder kinematics in shoulders with ICTs. Eight fresh-frozen cadaveric shoulders were tested in 5 conditions: (1) intact, (2) ICT (supraspinatus plus anterior half of infraspinatus), (3) SCR with dermal allograft, (4) SCR plus LDT, and (5) LDT alone. Rotational range of motion, superior translation, anteroposterior translation, and peak subacromial contact pressure were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Statistical analysis was performed using a repeated-measures analysis of variance test, followed by a Tukey post hoc test for pair-wise comparisons. ICTs increased total shoulder rotation, superior translation, posterior translation, and peak subacromial contact pressure. SCR plus LDT significantly decreased internal rotation only at 60° of abduction. The effect of SCR plus LDT was most evident at lower levels of abduction. At the mid range of abduction (30°), the static stabilizing effect diminished but the dynamic stabilizing effect remained, allowing SCR plus LDT to reduce superior translation more effectively than SCR with dermal allograft alone. Adding SCR to LDT adds static stabilization to a dynamic stabilizer. Therefore, SCR plus LDT may provide additional stability at the low to mid ranges of abduction.

Posterior and inferior glenosphere position in reverse total shoulder arthroplasty supports deltoid efficiency for shoulder flexion and elevation

02-04-2019 – Michel Meisterhans, Samy Bouaicha, Dominik C. Meyer

Journal Article

For humeral flexion and elevation, most relevant for daily activities with reverse total shoulder arthroplasty, the anterior and lateral deltoid muscles are most important. However, how this direction of movement is best supported with the glenosphere position is not fully understood. We hypothesized that both inferior positioning and posterior positioning of the glenosphere may best support this direction of movement. A validated, anatomic biomechanical shoulder model was modified to host a reverse shoulder prosthesis. The glenoid baseplate was altered to allow inferior, lateral, and posterior center-of-rotation (COR) offsets. An optical tracking system was used to track the excursion of ropes simulating portions of various shoulder muscles during humeral abduction, elevation, and flexion. The inferior COR offset resulted in a significant increase in the deltoid moment arm in all 3 planes of motion. The lateral COR offset showed a significantly lower posterior deltoid moment arm during humeral abduction and a significantly lower lateral deltoid moment arm during humeral elevation. The posterior offset showed significantly larger anterior and lateral deltoid moment arms during humeral flexion. Owing to the oblique direction of the deltoid muscle across the shoulder joint, an inferior offset of the COR in reverse total shoulder arthroplasty increases the deltoid moment arm during abduction, elevation, and flexion, whereas it mainly supports humeral flexion at a posterior offset. For humeral elevation and flexion, favorable positioning of the glenosphere may, therefore, be defined by a more inferior and posterior placement compared with the non-offset position.

Continuously monitoring shoulder motion after total shoulder arthroplasty: maximum elevation and time spent above 90° of elevation are critical metrics to monitor

09-04-2019 – Ryan M. Chapman, Michael T. Torchia, John-Erik Bell, Douglas W. Van Citters

Journal Article

Traditional clinical shoulder range-of-motion (ROM) measurement methods (ie, goniometry) have limitations assessing ROM in total shoulder arthroplasty (TSA) patients. Inertial measurement units (IMUs) are superior; however, further work is needed using IMUs to longitudinally assess shoulder ROM before TSA and throughout post-TSA rehabilitation. Accordingly, the study aims were to prospectively capture shoulder elevation in TSA patients and to compare the results with healthy controls. We hypothesized that patients would have reduced maximum elevation before TSA compared with controls but would have improved ROM after TSA. A validated IMU-based shoulder elevation quantification method was used to continuously monitor 10 healthy individuals (4 men and 6 women; mean age, 69 ± 20 years) without shoulder pathology and 10 TSA patients (6 men and 4 women; mean age, 70 ± 8 years). Controls wore IMUs for 1 week. Patients wore IMUs for 1 week before TSA, for 6 weeks at 3 months after TSA, and for 1 week at 1 year after TSA. Shoulder elevation was calculated continuously, broken into 5° angle “bins” (0°-5°, 5°-10°, and so on), and converted to percentages. The main outcome measures were binned movement percentage, maximum elevation, and average elevation. Patient-reported outcome measures and goniometric ROM were also captured. No demographic differences were noted between the cohorts. Average elevation was not different between the cohorts at any time. Control maximum elevation was greater than pre-TSA and post-TSA week 1 and week 2 values. Time under 30° and time above 90° were equal between the cohorts before TSA. After TSA, patients showed decreased time under 30° and increased time above 90°. This study demonstrates that acute and chronic recovery after TSA can be assessed via maximum elevation and time above 90°, respectively. These results inform how healthy individuals and patients use their shoulders before and after TSA.

The pathoanatomy of the anterior bundle of the medial ulnar collateral ligament

28-04-2019 – Rik J. Molenaars, Michel P.J. van den Bekerom, Denise Eygendaal, Luke S. Oh

Journal Article

The purpose of this study was to increase our understanding of the pathoanatomy of the ulnar collateral ligament (UCL) by performing a descriptive analysis of the surgical inspection of the anterior bundle in patients undergoing reconstruction. A single-surgeon series of 163 patients who underwent UCL reconstruction between 2009 and 2017 was retrospectively analyzed. Descriptions of the pathoanatomy of injury were obtained from the operative reports. Magnetic resonance imaging data were reviewed to assess whether the presence and location of tissue disruptions were accurately recognized. Demographic and clinical characteristics were obtained from medical records and correlated to observed pathoanatomy. Injuries to the anterior bundle were characterized by a single tissue disruption (65%), tissue disruptions at more than 1 location (23%), or injuries without distinct fiber tissue disruptions (12%). The presence and location of tissue disruptions matched magnetic resonance imaging findings in 124 of 153 patients (81%). Partial tears more frequently affected the anterior band of the anterior bundle distally as opposed to the posterior band of the anterior bundle proximally (P = .012). Patients with single tissue disruptions more frequently reported a popping sensation than patients with non-tear insufficiency (P = .030). This study shows the heterogeneity of anterior bundle injuries in patients undergoing UCL reconstruction. A variety of injury configurations and chronic attritional damage to the anterior bundle were observed, as well as distinct tear patterns at the distal and proximal attachment sites. Future research may elucidate the diagnostic value of a pop sign for UCL injury.

Influence of advanced glycation end products on rotator cuff

15-04-2019 – Yutaka Mifune, Atsuyuki Inui, Tomoyuki Muto, Hanako Nishimoto, Takeshi Kataoka, Takashi Kurosawa, Kohei Yamaura, Shintaro Mukohara, Takahiro Niikura, Takeshi Kokubu, Ryosuke Kuroda

Journal Article

Most rotator cuff tears are the result of age-related degenerative changes, but the mechanisms underlying these changes have not been reported. Recently, advanced glycation end products (AGEs) have been regarded as an important factor in senescence. Therefore, we hypothesized that AGEs would have detrimental effects on rotator cuff-derived cells. In this study, we investigated the influence of AGEs on rotator cuff-derived cells in vitro and ex vivo. Rotator cuff-derived cells were obtained from human supraspinatus tendons. The cells were cultured in the following media: (1) regular medium with 500 μg/m
L AGEs (High-AGEs), (2) regular medium with 100 μg/m
L AGEs (Low-AGEs), and (3) regular medium alone (Control). Cell viability, secretion of vascular endothelial growth factor, and the expressions of hypoxia-inducible factor-1α, reactive oxygen species, and apoptosis were assessed after cultivation. An ex vivo tissue culture with AGEs was also performed to measure the tensile strength. Cell viability in the High-AGEs group was significantly suppressed relative to that in the Controls. The amount of vascular endothelial growth factor secretion was significantly greater in the High- and Low-AGEs groups than in the Controls. Immunofluorescence stain demonstrated enhancement of hypoxia-inducible factor-1α and reactive oxygen species expressions and cell apoptosis in the High- and Low-AGEs groups relative to that in the Controls. In ex vivo mechanical testing, tensile strength was significantly higher in the Control group than in the AGEs groups. These results indicated that AGEs caused age-related degenerative rotator cuff changes. The reduction of AGEs might prevent rotator cuff senescence-related degeneration.

Impact of ball weight on medial elbow torque in youth baseball pitchers

06-05-2019 – Kelechi R. Okoroha, Jason E. Meldau, Toufic R. Jildeh, Jeffrey P. Stephens, Vasilios Moutzouros, Eric C. Makhni

Journal Article

Our hypothesis was that an increase in ball weight would result in an increase in medial elbow torque during the pitching motion. Youth pitchers were recruited for this study and instructed to throw 5 maximum-effort fastballs from ground level using baseballs of 4 different weights: 85 g (3 oz), 113 g (4 oz), 142 g (5 oz), and 170 g (6 oz). The validated Motus sensor was used to assess medial elbow torque, arm speed, arm slot, and shoulder rotation for each pitch. Pitch velocity was measured using a radar gun. Relationships between baseball weight and pitching kinetics and/or kinematics were evaluated using linear mixed-effects analysis. An exit survey was conducted detailing the pitcher’s evaluation of the ball weights used. A total of 19 youth baseball pitchers (average age, 11.8 ± 1.1 years; age range, 9-14 years) completed the study. For every 1-oz (28-g) increase in ball weight, ball velocity decreased 2.0 ± 0.1 mph (χ Among youth pitchers, an increase in ball weight correlated with greater medial elbow torque, decreased pitch velocity, and decreased arm speed.

Brachioradialis muscle flap for posterior elbow defects: a simple and effective solution for the upper limb surgeon

23-06-2019 – Frantzeska Zampeli, Sarantos Spyridonos, Emmanouil Fandridis

Journal Article

Trauma, infection, and posterior surgical approach are the most frequent causes of soft tissue defects of posterior elbow. The brachioradialis (BR) muscle flap is a rotational muscular pedicled flap, and the dominant vascular pedicle arises from the radial recurrent artery in the proximal portion of the muscle. The aim of the study was to present the BR muscle flap as a simple, safe, and effective solution for the treatment of soft tissue defects of the posterior elbow. Five patients (3 males; mean age, 61.4 years; range, 40-73 years) with soft tissue defects of the posterior elbow underwent surgical treatment with the BR muscle flap. The causes of the defects were total elbow arthroplasty and postsurgical infection (n = 2), 1 patient with elbow arthrodesis due to neuropathic arthropathy, and postsurgical infection after open reduction and internal fixation of olecranon fractures (n = 2). All patients had a BR muscle flap and skin grafting. Orthopedic hardware was removed in 3 cases. At the mean follow-up of 45 months (range, 26-61 months), all patients had viable and functional soft tissue coverage. All patients were free of infection, whereas 1 patient had a posterior elbow discomfort in daily activities. None of the patients reported wrist problems. The BR muscle flap is a reliable solution, easy to harvest without requiring microsurgical expertise for small-size posterior elbow defects. It is a 1-stage procedure with no morbidity to the harvest site that provides stable and adequate coverage even in cases with postoperative infection.

Idiopathic anterior dislocation of the radial head: symptoms, radiographic findings, and management of 8 patients

23-07-2019 – Muneaki Abe, Hozumi Kumano, Akihiko Kinoshita, Atsushi Yokota, Katsunori Ohno

Journal Article

Radial head dislocation may occur during trauma or in association with congenital diseases, or it may be developmental or idiopathic. Reports of idiopathic dislocation of the radial head have been scarce. The symptoms, radiographic findings, and management of idiopathic dislocation of the radial head have not been well described in the literature. During the past 28 years, we have encountered 8 cases of idiopathic anterior dislocation of the radial head (mean patient age, 12.5 years). In only 1 case did the patient and/or the patient’s parents recall any preceding trauma or injury to the affected limb. Patients’ complaints included a bulging mass, pain, and limited elbow flexion. Radiographically, the shape of the radial head was flat or slightly convex. Seven of the patients were treated with open reduction of the radial head and angulation osteotomy of the ulna. The other patient’s radial head was stabilized without osteotomy. The mean postoperative follow-up period was 4.5 years. In patients whose elbow flexion was limited before surgery, improvement to more than 125° occurred. The bulging mass in the cubital fossa disappeared. None of the patients complained of disability during activities of daily living or sports participation. Radiographically, the radial head remained in the reduced position in all patients in whom open reduction of the radial head with angulation osteotomy of the ulna was performed. We have described the symptoms, radiographic characteristics, and treatment of idiopathic anterior dislocation of the radial head. Open reduction of the radial head combined with angulation osteotomy of the ulna yielded favorable results both clinically and radiographically.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases

05-02-2019 – Michael Hackl, Kilian Wegmann, Boris Hollinger, Bilal F. El-Zayat, Dominik Seybold, Thorsten Gühring, Marc Schnetzke, Kay Schmidt-Horlohé, Stefan Greiner, Helmut Lill, Alexander Ellwein, Michael C. Glanzmann, Sebastian Siebenlist, Martin Jäger, Jörg Weber, Lars P. Müller

Journal Article

Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures. This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case. The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision. The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.

Component fracture after total elbow arthroplasty

12-05-2019 – Homin Lee, Anthony M. Vaichinger, Shawn W. ODriscoll

Journal Article

Ulnar or humeral component stem fractures after total elbow arthroplasty (TEA) are serious complications. We hypothesized that TEA stem component fractures are fatigue fractures that result from periarticular osteolysis caused by bushing wear, which leads to a region of unsupported stem adjacent to a region where the stem is well-fixed. A review of 2637 primary and revision TEA cases from 1972 to 2016 revealed that 47 operations in 46 patients were complicated by or performed to deal with component stem fractures. Bushing wear was graded according to percentage loss of polyethylene thickness and metal wear. In the 39 cases in which bushing wear was able to be quantitated, it was severe in 34, moderate in 2, and mild in 3. Radiographs at final follow-up were available in 47 cases. All 47 cases showed evidence of periarticular osteolysis, which was in zone 1 in 17, in zones 1 and 2 in 29, and diffuse in 1. The length of the well-fixed stem, expressed as a percentage of total stem length, averaged 63% (range, 29%-86%). Stem fractures most often (27 of 47 cases) occurred at the junction between the well-fixed stem and unsupported stem. The median distance between the site of stem fracture and the unsupported-well-fixed stem junction was 0 mm (interquartile range, 0-5 mm). On the basis of our findings, a component stem fracture after TEA seems to occur by fatigue failure at or near the junction between an unsupported stem and well-fixed stem. This area of unsupported stem occurs as a result of osteolysis caused by bushing wear. The solution for component fractures requires a solution for bushing wear.

Low return-to-sports rate after elbow injury and treatment with radial head arthroplasty

23-06-2019 – Matthias Jung, Corinna Groetzner-Schmidt, Felix Porschke, Paul A. Grützner, Thorsten Guehring, Marc Schnetzke

Journal Article

The aim of this study was to analyze sports participation after radial head arthroplasty among recreational athletes. A total of 57 recreational athletes (mean age, 49 years; age range, 18-79 years) treated with radial head arthroplasty for non-reconstructible radial head fractures were included in this retrospective study. The return-to-sports rate and the time to return to sports were analyzed. The clinical and radiologic outcomes were compared between patients who returned to sports (group 1) and those who did not (group 2). After a mean follow-up period of 8.4 years (range, 2.5-16.4 years), 30 of 57 patients (53%) had returned to sports. The mean sports frequency significantly decreased from 5.2 ± 5.0 h/week to 2.2 ± 2.9 h/week after surgery (P < .001). In group 1, 83% of patients returned to the same sports activity whereas 17% changed to a less demanding sports activity. The mean time to return to sports was 158 days (range, 21-588 days). Patients who returned to sports had a significantly better Mayo Elbow Performance Score (MEPS) (84 ± 19 points vs. 63 ± 20 points, P < .001); Disabilities of the Arm, Shoulder and Hand score (16 ± 17 vs. 46 ± 22, P < .001); and arc of flexion (114° ± 32° vs. 89° ± 36°, P = .007). A secondary radial head prosthesis (P = .046) and MEPS lower than 85 points (P = .001) were associated with a significantly lower return-to-sports rate. No differences regarding radiographic changes were found between the 2 groups (P ≥ .256). The return-to-sports rate after radial head replacement is low. A secondary radial head prosthesis and a worse clinical outcome (MEPS < 85 points) significantly increase the risk of not returning to sports after radial head arthroplasty.

Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures

23-07-2019 – Prakash Jayakumar, Teun Teunis, Ana-Maria Vranceanu, Meredith Grogan Moore, Mark Williams, Sarah Lamb, David Ring, Stephen Gwilym

Journal Article

The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury. We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points. Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.

In search of consensus—ICSES 2019

24-06-2019 – Daniel Moya, Gastón Maignón, Marcelo Vila


Response to Long etxa0al regarding: “Cutibacterium acnes and the shoulder microbiome”

23-07-2019 – David B. OGorman, Ana M. Pena-Diaz, Darren Drosdowech, Kenneth J. Faber, George S. Athwal, Jeremy P. Burton, Kait Al, Tony Huang, Boyang Qiu


Letter to the Editor regarding Qui etxa0al: “Cutibacterium acnes and the shoulder microbiome”

23-07-2019 – Dustin R. Long, Jason E. Hsu, Stephen J. Salipante, Roger E. Bumgarner


Mycobacterium tuberculosis infection of reverse shoulder arthroplasty: a case report

23-07-2019 – Thomas Amouyel, Pierre Gaeremynck, Benjamin Gadisseux, Marc Saab, Eric Senneville, Carlos Maynou

Journal Article

Reverse total shoulder arthroplasty and resting radiographic scapular rotation

18-04-2019 – Timothy L. Kahn, Erin K. Granger, Heath B. Henninger, Robert Z. Tashjian, Peter N. Chalmers

Journal Article

It remains unclear whether changes in scapular rotation influence the surgeon’s ability to achieve resting radiographic neutral or inferior baseplate tilt at final follow-up. The purposes of this study were (1) to determine whether reverse total shoulder arthroplasty (RTSA) changes the resting scapular rotation, (2) to determine the association between glenoid inclination with respect to the scapula (β angle) and resting scapular rotation, and (3) to determine the β angle threshold that will most likely lead to resting radiographic neutral or inferior baseplate tilt relative to the thorax. This was a retrospective radiographic study. Patients with adequate-quality standing anteroposterior and Grashey radiographs obtained preoperatively and after primary RTSA at a minimum of 1 year were included. Glenoid inclination (β angle) was measured between the supraspinatus fossa and the glenoid. Resting scapular rotation was measured between the supraspinatus fossa and a vertical line. Baseplate tilt was then calculated as the angle between the glenoid and a vertical line. The study included 74 patients with a mean follow-up period of 3 years (range, 1-9 years). Scapular rotation changed 2° ± 12° (mean ± standard deviation) into upward rotation (P = .048). No association was found between the β angle and scapular rotation. In 71% of patients with a neutral or inferior baseplate tilt, a postoperative β angle greater than 85° was found. Resting radiographic scapular rotation changed 2° into upward rotation with RTSA and was not associated with the β angle. If the β angle is greater than 85°, resting radiographic baseplate tilt will most likely be inferior or neutral.