Journal of Shoulder and Elbow Surgery

ASES 2019 presidential address

19-02-2020 – Frank A. Cordasco


“Response to Chelli and Boileau: “Lets ‘recall’ sensitivity and specificity””

19-02-2020 – Anirudh K. Gowd, Dev M. Patel, Avinesh Agarwalla, Edward C. Beck, Anthony A. Romeo, Joseph N. Liu


Letter to the Editor regarding Yagnik etxa0al: “A biomechanical comparison of new techniques for distal clavicular fracture repair versus locked plating”

19-02-2020 – Alexander Van Tongel, Lieven De Wilde


Response to Liu and Amin regarding: “Severe subacromial-subdeltoid inflammation with rice bodies associated with implantation of a bio-inductive collagen scaffold after rotator cuff repair”

19-02-2020 – Steven J. Barad


Letter to the Editor regarding Barad: “Severe subacromial-subdeltoid inflammation with rice bodies associated with implantation of a bio-inductive collagen scaffold after rotator cuff repair”

19-02-2020 – Joseph N. Liu, Nirav H. Amin


Rib fracture as a complication of erroneous baseplate and inferior screw placement in reverse total shoulder replacement: axa0case report

19-02-2020 – Robert D.J. Whitham, Zoë J. Clifford, Andrew J.B. Tasker, David A. Woods

Case Reports

A new pathologicxa0classification for elbow stiffness based on our experience in 216 patients

05-11-2019 – Ziyang Sun, Juehong Li, Haomin Cui, Hongjiang Ruan, Wei Wang, Cunyi Fan

Journal Article

Elbow stiffness commonly causes functional impairment and upper-limb disability. This study aimed to develop a new pathologic classification to further understand and standardize elbow arthrolysis from a new perspective, as well as to determine clinical outcomes. Extension-flexion dysfunction was classified into 4 types: EF Mean range of motion (ROM) increased from 40° preoperatively to 118° at final follow-up; 88% of patients regained ROM of 100° or greater. The forearm rotation arc (FRA) with forearm rotation dysfunction increased from a preoperative mean of 76° to 128°; 82% of patients regained an FRA of 100° or greater. The mean Mayo Elbow Performance Index (MEPI) increased from 63 to 91 points; the proportion of patients with good or excellent results was 95%. EF This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes.

Predictors of patient satisfaction after reverse shoulder arthroplasty

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

Journal Article

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

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

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

Journal Article

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

Clinical outcomes following conservative and surgical management of floating shoulder injuries: a systematic review

10-12-2019 – Alex R. Dombrowsky, Sellers Boudreau, Jon Quade, Eugene W. Brabston, Brent A. Ponce, Amit M. Momaya

Journal Article, Review

Floating shoulder is an uncommon injury characterized by fractures of the clavicle and ipsilateral scapular neck. No consensus exists on management. The purpose of this study was to analyze the existing literature on treatment and clinical outcomes of floating shoulder injuries to provide a baseline understanding of current treatment strategies of this injury. A systematic review was performed to identity published literature on outcomes and management of floating shoulder injuries. Searches were performed using PubMed, Embase, and SCOPUS. Seventeen studies were identified that included data for 371 shoulders. The mean reported age was 39.4 years (range, 16-82) and the mean follow-up was 49.4 months (range, 6-312). The major mechanism of injury was motor vehicle accident (51%) followed by fall from height (16%). Of the 371 shoulders, 215 (58%) were treated surgically, whereas 156 shoulders (42%) were managed nonoperatively. The most commonly reported outcome score was the Constant-Murley score (9 studies), followed by the Herscovici Floating Shoulder Injury score (5 studies). The mean Constant-Murley score was 80% of ideal maximum for both shoulders treated surgically and those treated nonoperatively. Satisfactory outcomes can be expected following both surgical fixation and nonoperative management of floating shoulder injuries when appropriately individualized to the patient, as evidenced by clinical outcome scores. Floating shoulder injuries with significant displacement of the scapular neck may benefit from surgical fixation of both the clavicle and scapula fractures. In those with minimal or nondisplaced scapular neck fractures, good outcomes may be achieved when treated nonoperatively or with surgical fixation of the clavicle alone.

Revision rotator cuff repair: a systematic review

02-09-2019 – Robert L. Brochin, Ryley Zastrow, Lindsay Hussey-Andersen, Bradford O. Parsons, Paul J. Cagle

Journal Article

The incidence of revision rotator cuff repair (RCR) has increased along with the incidence of primary RCR over the past 2 decades. The purpose of this study was to perform a systematic review to analyze the clinical outcomes of revision RCR and chiefly to identify prognostic factors that may influence postoperative outcomes. The PubMed, MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library (Wiley) databases were searched from database inception through November 2018 for studies assessing revision RCR. All studies were screened in duplicate for eligibility. Pooled analysis correlations between mean preoperative range-of-motion measures, American Shoulder and Elbow Surgeons (ASES) scores, and visual analog scale (VAS) pain scores and mean postoperative outcomes with revision RCR were examined via linear regression and reported with the strength of the Spearman correlation coefficient (r A total of 22 studies met the inclusion criteria, including 3 level III and 19 level IV studies. Mean preoperative forward flexion had the greatest correlation with the mean postoperative ASES score (r The results of this systematic review demonstrate favorable clinical outcomes following RCR revision performed both in an open manner and arthroscopically. Preoperative forward flexion was identified as a possible prognostic factor for improved outcomes.

Computer navigation of the glenoid component in reverse total shoulder arthroplasty: a clinical trial to evaluate the learning curve

28-10-2019 – Allan W. Wang, Alex Hayes, Rebekah Gibbons, Katherine E. Mackie

Journal Article

Intraoperative computer navigation has been introduced recently to assist with placement of the glenoid component. The aim of this study was to evaluate the learning curve of a single surgeon performing computer navigation of glenoid implant placement in primary reverse total shoulder arthroplasty (RTSA). Following training with the intraoperative computer navigation system, we conducted a prospective case-series study of the first 24 consecutive patients undergoing a primary RTSA with navigation performed by a single surgeon. Surgical times, complications, and accuracy of glenoid positioning compared with the preoperative plan were evaluated. Surgical times were compared with the preceding non-navigated series of 24 consecutive primary RTSA cases. Postoperative 3-dimensional computed tomography scans were performed to evaluate glenoid component version and inclination compared with the preoperative plan. The total surgical time was 77.3 minutes (standard deviation [SD], 11.8 minutes) in the navigated RTSA cohort and 78.5 minutes (SD, 18.1 minutes) in the non-navigated series. A significant downward trend in the total surgical time was observed in the navigated cohort (P = .038), which flattened after 8 cases. No learning curve was observed in deviation of glenoid version or inclination from the preoperative plan. The mean deviation of achieved version from planned version was 3° (SD, 2°), and the mean deviation of achieved inclination from planned inclination was 5° (SD, 3°). Findings from this study suggest that intraoperative computer navigation will not require substantially increased operating times compared with standard surgical techniques. With prior surgeon training, approximately 8 operative cases are required to achieve proficiency in intraoperative computer navigation of the glenoid component.

A 3-dimensional comparison of hand and power reamers in accuracy of glenoid retroversion correction

02-11-2019 – Michael Scheidt, Michael Wesolowski, Dane Salazar, Nickolas Garbis

Journal Article

The study objective was to compare the reaming congruency of hand, power, and visual feedback axial alignment-guided (Marksman) reamers on glenoid models. We hypothesized that (1) a significant difference in average reaming deviation would be found between reamer types and (2) less ream-to-ream variation would occur with the Marksman reamer. Retroversion correction of 18 identical Sawbones glenoid models was conducted using either a hand, power, or Marksman reamer with a 40-mm curvature radius. Glenoid correction with either 0° or 10° reaming was conducted in triplicate sets for each reamer. Reamed glenoid computed tomography images were 3-dimensionally reconstructed using Mimics Medical software (version 21.0). Congruency between the glenoid surface and a 3-dimensional sphere with a 40-mm curvature radius was analyzed. Average deviation and ream-to-ream variance were compared between the hand, power, and Marksman reamer groups. The power reamer demonstrated the smallest median deviation (0.08 mm; interquartile range [IQR], 0.07-0.19 mm), followed by the Marksman (0.09 mm; IQR, 0.08-0.17 mm) and hand (0.11 mm; IQR, 0.10-0.13 mm) reamers. Kruskal-Wallis analysis indicated no significant difference in deviation among the 3 reaming methods (P = .42). The Marksman reamer demonstrated the least variance (0.0034 mm), followed by the power (0.0076 mm) and hand (0.0093 mm) reamers. The results of the Conover squared ranks test indicated no significant difference in variance among the 3 reaming methods (P = .32). Our findings showed no statistically significant difference in the accuracy or consistency of reaming between reamer types. Trends showed less variance in the Marksman reamer group compared with the hand and power reamer groups, although differences in variation between groups were not statistically significant.

Subacromial space outlet in female patients with multidirectional instability based on hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder measured by ultrasound

21-10-2019 – Birgitte Hougs Kjær, Inge de Wandele, Valentien Spanhove, Birgit Juul-Kristensen, Ann M. Cools

Journal Article

The objective of the study was to compare the acromiohumeral distance (AHD) between patients diagnosed with hypermobility type of the Ehlers-Danlos syndrome (h
EDS) or hypermobility spectrum disorder (HSD) and healthy controls by evaluating the relative amount the tendon occupies in the subacromial area. Furthermore, the aim was to evaluate if there was a change in AHD with arm elevation within and between groups. Twenty-nine female patients with h
EDS/HSD (aged 34 ± 12.9 years) and 20 healthy controls (aged 33 ± 10.8 years) participated in the study. The supraspinatus tendon (SST) thickness and AHD were measured using ultrasound. The interplay between the SST and the AHD was expressed as the occupation ratio (OcAHD), calculated as the SST thickness as a percentage of AHD. The measures were performed in the resting position and in subsequently 45° and 60° of active arm elevation in the scapular plane. The main finding is that patients with h
EDS/HSD have a larger subacromial space outlet compared with the controls when measured by ultrasound. Furthermore, in both groups, we found an increased OcAHD during active arm elevation compared with the resting position, which indicates that similar mechanisms occur for patients with h
EDS/HSD and healthy controls. Patients with h
EDS/HSD have a larger available subacromial space outlet compared with healthy individuals. OcAHD increased during active arm elevation compared with the resting position in both groups. This knowledge is important when designing rehabilitation exercise programs for shoulder instability patients with abnormal glenohumeral biomechanics.

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

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

Journal Article

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

Importance of radar gun inclusion during return-to-throwing rehabilitation following ulnar collateral ligament reconstruction in baseball pitchers: a simulation study

21-12-2019 – Vincent A. Lizzio, D. Grace Smith, Toufic R. Jildeh, Caleb M. Gulledge, Alexander J. Swantek, Jeffrey P. Stephens, Brian M. Schulz, Eric C. Makhni

Journal Article

Rehabilitation following elbow ulnar collateral ligament reconstruction in baseball pitchers relies on a progression of pitching activities to ensure protection and gradual strengthening of the reconstructed ligament. The purpose of this study was to determine the medial elbow torque associated with pitches at various effort levels and determine whether radar gun assistance improves players’ abilities to accurately match partial-effort pitches with true references based on maximum pitch velocity. Thirty-seven healthy high school and collegiate baseball pitchers were included in this study. Participants were excluded if they were injured, recovering from injury, or otherwise not currently pitching at full effort. Pitch parameters were collected using a validated wearable sensor. Participants threw 5 pitches at 50%, 75%, and 100% subjective effort. Pitchers then threw 5 pitches at 50% maximum velocity and 75% maximum velocity, as measured by a radar gun. Thirty-seven pitchers completed this study. Pitches thrown at 50% and 75% partial effort were significantly faster and generated higher elbow torque than did pitches thrown at 50% and 75% velocity, respectively (P < .001). A 10% decrease in percentage of maximum velocity was associated with a 13% decrease in percentage of maximum elbow torque (β coefficient = 1.3, R Pitchers generate higher-than-intended forces when throwing at 50% and 75% effort during a subjective partial-effort throwing protocol. Use of a radar gun to guide partial-effort throwing during throwing rehabilitation programs may protect the reconstructed elbow from excess medial torque.

Valgus stress ultrasound for medial ulnar collateral ligament injuries in athletes: is ultrasound alone enough for diagnosis?

19-02-2020 – Jin-Young Park, Heedong Kim, Jae-Hyung Lee, Taehaeng Heo, Hyunjun Park, Seok Won Chung, Kyung-Soo Oh

Journal Article

We hypothesized that valgus stress ultrasound would be useful for both identifying medial ulnar collateral ligament (MUCL) tears and assessing the severity of the tears. Hence, we performed valgus stress ultrasound of the elbow in athletes with MUCL injuries, confirmed by magnetic resonance imaging (MRI), to determine whether ultrasound can be used as a diagnostic tool. Stress ultrasound and MRI data from 146 athletes with medial elbow pain were compared prospectively. MRI findings for MUCL injuries were classified into 3 levels as follows: low-grade partial tear (≤50%), high-grade partial tear (>50%), and complete tear. The degree of joint laxity on stress ultrasound was evaluated by measuring joint gapping after applying a 2.5-kg load to the wrist. Joint gapping was measured at 30° and 90° of elbow flexion for the dominant arm and nondominant arm, and the differences between the dominant and nondominant arms were determined. A higher degree of MUCL injury on MRI was associated with greater joint gapping in the medial elbow on stress ultrasound. At 30° of elbow flexion, the cutoff value for complete MUCL rupture was 0.5 mm (P < .001), with a sensitivity and specificity of 88.1% and 61.5%, respectively. At 90° of elbow flexion, the cutoff value for complete MUCL rupture was 1.0 mm (P < .001), with a sensitivity and specificity of 81.0% and 66.4%, respectively. Stress ultrasound can be used to diagnose complete MUCL tears in athletes when joint gapping is greater than 0.5 mm at 30° of elbow flexion and greater than 1 mm at 90° of elbow flexion.

Assessment of posterior shoulder muscle stiffness related to posterior shoulder tightness in college baseball players using shear wave elastography

10-09-2019 – Yutaka Mifune, Atsuyuki Inui, Hanako Nishimoto, Takeshi Kataoka, Takashi Kurosawa, Kohei Yamaura, Shintaro Mukohara, Takahiro Niikura, Takeshi Kokubu, Toshihiro Akisue, Ryosuke Kuroda

Journal Article

Limitations of shoulder range of motion (ROM) have been reported to be at high risk for shoulder disorders in baseball players. In this study, we assessed posterior shoulder muscle stiffness using shear wave elastography in baseball players with and without posterior shoulder tightness. In total, 21 college baseball players volunteered to participate in this study. Passive ROMs for shoulder abduction and horizontal adduction were measured using a goniometer. Subsequently, we divided all participants into 2 groups based on the differences between bilateral shoulder ROMs: STIFF+ and STIFF- groups. Thickness and elasticity of the posterior and inferior shoulder muscles were assessed using ultrasound. Shoulder abduction ROM on the throwing side was 114.5° ± 5.3° and 131.3° ± 5.7° in the STIFF+ and STIFF- groups, respectively, which was significantly different between the 2 groups (P = .023). Horizontal adduction ROM on the throwing side was 96.6° ± 4.9° and 110.9° ± 4.8° in the STIFF+ and STIFF- groups, respectively, which was also significantly different between the 2 groups (P = .014). The elasticity of infraspinatus and lower trapezius in the STIFF+ group was significantly greater than that in the STIFF- group (P = .018 and .033, respectively). In this study, we found that the elasticity of infraspinatus and lower trapezius in stiff shoulders was significantly greater than that in nonstiff shoulders, which indicated that the infraspinatus and lower trapezius could be the key muscles in posterior shoulder tightness.

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

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

Journal Article

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

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

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

Journal Article

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

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

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

Journal Article

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

Structural glenoid allograft reconstruction during reverse total shoulder arthroplasty

19-09-2019 – Robert Z. Tashjian, Kortnie Broschinsky, Irene Stertz, Peter N. Chalmers

Journal Article

Large glenoid defects present a challenge during primary and revision reverse total shoulder arthroplasty (RTSA) especially when humeral head autograft is not available as a bone graft source. The purpose of this study was to evaluate the clinical and radiographic outcomes of RTSA with concomitant structural allografting to reconstruct large glenoid defects. From May 2008 to July 2016, 22 patients underwent primary or revision RTSA with structural glenoid allografting. Of 22 patients, 19 (86%) were available for a minimum 2-year clinical follow-up (average, 2.8 ± 1.3 years), and 17 of 22 (77%) were available for a minimum 1-year radiographic follow-up. Functional outcomes, range of motion, radiographic deformity correction, allograft incorporation, and complication rates were determined. From preoperatively to postoperatively, significant improvements in the average Simple Shoulder Test score (2 ± 2 preoperatively vs. 10 ± 8 postoperatively, P = .002), the average American Shoulder and Elbow Surgeons score (31 ± 19 preoperatively vs. 70 ± 25 postoperatively, P < .001), and average active forward elevation (71° ± 41° preoperatively vs. 128° ± 28° postoperatively, P < .001) were noted. Coronal-plane radiographic correction was 29° ± 12° as measured with the reverse shoulder arthroplasty angle (P < .001) and 14° ± 11° as measured with the β angle (P < .001). Postoperatively, of 17 patients with a minimum 1-year radiographic follow-up, 14 (82%) had complete radiographic incorporation of the graft. Acromial fracture nonunions developed in 2 patients and loosening and migration of the baseplate were found in 2 patients, although no patients elected to undergo further surgery. RTSA with allograft reconstruction of severe glenoid defects allows restoration of glenoid anatomy and leads to high rates of bony incorporation with low rates of glenoid loosening or requirement for revision. Structural allograft is an excellent alternative to autograft in revision RTSA to avoid graft-site morbidity.

Arthroscopic rotator cuff repair using a transosseous knotless anchor (ATOK)

30-09-2019 – Michael J. Sandow, Christine R. Schutz

Journal Article

This article reviews the clinical and radiographic outcomes in a noninferiority trial use of a transosseous knotless anchor to perform arthroscopic rotator cuff repairs in a patient cohort that have an increased incidence of osteoporosis. Patients aged over 60 with a documented rotator cuff tear and who failed a rehab program underwent repair using an arthroscopic transosseous knotless (ATOK) anchor. Patients were prospectively reviewed using shoulder functional assessments (age-adjusted Constant score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores), and underwent preoperative as well as 1-, 3-, and 12-month postoperative magnetic resonance imaging. 15 patients had undergone rotator cuff repair using the ATOK and were followed for a minimum of 24 months (range 24-30 months). From preoperative to 24 months post repair, median scores improved for ASES (61-89), Oxford (26-44), Constant (62-91), and VAS Pain (5-0.5). Four patients developed a partial retear of their repair, but only 1 patient sustained a complete retear: Sugaya type I, 10; type II, 1; type III, 2; type IV, 1; and type V, 1. No anchors were displaced, and there were no osteolysis, neurologic, or technique-related complications. Arthroscopic rotator cuff repairs using a transosseous knotless technique has achieved a satisfactory outcome in this group of patients, who typically have poor bone quality, increasing the risk of antegrade anchor pullout. This approach would appear to combine the potential biomechanical and biological advantages of a transosseous repair technique, with the benefits of the lower morbidity arthroscopic surgical approach.

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

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

Journal Article

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

The accuracy of joint aspiration for the diagnosis of shoulder infections

30-09-2019 – Andreas Hecker, Anna Jungwirth-Weinberger, Michael Robert Bauer, Timo Tondelli, Ilker Uçkay, Karl Wieser

Journal Article

Shoulder joint aspirations are frequently performed to rule out infection. In case of unsuccessful aspiration, physicians often augment the aspiration liquid by injecting saline solution. We performed shoulder joint aspirations by fluoroscopic assistance and analyzed the value of an additional saline solution irrigation in patients undergoing revision shoulder surgery. Native joints and post-fracture repair, post-arthroscopy, and post-arthroplasty shoulders were included. A minimum of 3 deep intraoperative tissue samples served as the microbiological gold standard. We performed 106 aspirations occurring between 0 and 179 days before revision surgery. Among them, we could sample intra-articular liquid directly in 60 cases and after saline solution injection in 43 cases, whereas 3 cases remained unsuccessful. According to intraoperative samples, 24 shoulders were infected but only 10 of 24 (42%) yielded pathogens in the aspirate. Moreover, of the 43 saline solution-enforced irrigations, none revealed bacteria but 8 (17%) confirmed infection in intraoperative samples. Overall, the sensitivity, specificity, positive predictive value, and negative predictive value of presurgical aspirations were 33%, 98%, 80%, and 83%, respectively. When surgical revision is planned, presurgical shoulder joint aspiration is not reliable to sufficiently exclude shoulder joint infection. Nevertheless, a positive aspiration finding can guide clinical decision making, so we propose to perform aspiration only if there is a clinically high index of suspicion for an infection. Irrigation after unsuccessful primary aspiration is futile.

Study of variations in inpatient opioidxa0consumption after total shoulder arthroplasty: influence of patient- and surgeon-related factors

10-09-2019 – Oluwadamilola O. Kolade, Niloy Ghosh, Laviel Fernandez, Scott Friedlander, Joseph D. Zuckerman, Joseph A. Bosco, Mandeep S. Virk

Journal Article

The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization. The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption. Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P < .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P < .001), age < 60 years (P < .01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences. There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.

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

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

Journal Article

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

Risk factors for failure of eradicating infection in a single arthroscopic surgical procedure for septic arthritis of the adult native shoulder with a focus on the volume of irrigation

23-09-2019 – Yong-Bum Joo, Woo-Yong Lee, Hyun Dae Shin, Kyung Cheon Kim, Yun-Ki Kim

Journal Article

Septic arthritis of a native joint is relatively rare but is still a challenging and important orthopedic emergency. Most previous reports have focused on the clinical outcomes rather than the risk factors for failure in arthroscopic surgery. We retrospectively reviewed the records of patients with septic monoarthritis of the shoulder who underwent arthroscopic irrigation and débridement between January 2007 and January 2019. All patients were divided into 2 groups according to recurrence after a single arthroscopic surgical procedure: eradicated group or recurred group. To identify risk factors affecting the recurrence of septic arthritis of the shoulder after arthroscopic surgery, the following parameters were considered: age; sex; involved side; presentation of rotator cuff tear; volume of irrigation; bacterial organism involved; preoperative erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count in blood and joint fluid; diabetes mellitus; and hypertension. We compared the eradicated and recurred groups regarding the presence of potential risk factors. The study included 97 patients with a mean age of 61 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgical procedure in 85 patients. However, a second arthroscopic surgical procedure was necessary in 12 patients (12.4%) because of infection recurrence. No significant differences were found between groups except in the volume of irrigation (P < .001). Most patients with septic arthritis (87.6%) of native shoulders were effectively treated with a single arthroscopic irrigation and débridement. The amount of irrigation may be the most important factor for preventing the need for additional surgical management.

Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients

15-09-2019 – Alyssa D. Althoff, Russell A. Reeves, Sophia A. Traven, Joshua M. Wilson, Shane K. Woolf, Harris S. Slone

Journal Article

The purpose of this study was to evaluate the association between smoking and postoperative complications following total shoulder arthroplasty. We hypothesized that active smokers would have significantly greater postoperative medical and surgical complications. The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent total shoulder arthroplasties from 2005 through 2016. Patients were stratified based on tobacco use within the past year. Logistic regression was used to assess the relationship between smoking status and postoperative medical and surgical complications. Multivariate logistic regression was used to adjust for demographic and comorbid factors. We identified 14,465 patients, of whom 10.5% were active smokers. Smokers were more likely to be younger, to be female patients, and to have a lower body mass index compared with nonsmokers (P .05) but was associated with an increased risk of overall surgical complications (odds ratio [OR], 3.259; 95% confidence interval [CI], 1.861-5.709; P < .001). Multivariate modeling showed that smoking increased the risk of wound complications (adjusted OR, 7.564; 95% CI, 2.128-26.889; P = .002) and surgical-site infections (adjusted OR, 1.927; 95% CI, 1.023-3.630; P = .042). This study demonstrates that smoking is associated with an increased risk of surgical complications following total shoulder arthroplasty. On the basis of our available data, medical complications are not significantly increased. This information can help risk stratify patients prior to their procedures.

Shoulder arthroplasty in patients with cerebral palsy: a matched cohort study to patients with osteoarthritis

30-09-2019 – Erick M. Marigi, Joseph M. Statz, John W. Sperling, Joaquin Sanchez-Sotelo, Robert H. Cofield, Mark E. Morrey

Journal Article

Patients with cerebral palsy (CP) often experience shoulder impairment via spasticity, muscle contractures, and joint instability. Currently, few studies investigate shoulder arthroplasty (SA) in patients with CP. This study reviewed the outcomes of both anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RSA) in patients with CP. Over a 30-year-period, 5 patients undergoing SA (2 TSA, 3 RSA) with a diagnosis of CP were identified. The cohort included 4 male patients with a mean age of 50.4 years (range, 44-58 years). CP patients were matched 1:2 based on age, sex, body mass index, and year of surgery with a group of patients undergoing SA for osteoarthritis (OA). Survival from implant revision for both TSA and RSA in CP was 100% at both 2 and 5 years postoperatively. Clinical complications were only observed in 2 patients after TSA, with 1 patient requiring revision at 14 years postoperatively. Collectively, there was no difference in the rate of complications and implant survival between patients with CP vs. OA. Prior to the surgical procedure, all CP patients had severe or moderate pain, with no moderate or severe pain postoperatively. Notable postoperative increases from preoperative baselines were noted in forward elevation (57°-106°), abduction (48°-84°), and external rotation (30°-64°). RSA had significantly improved postoperative abduction compared to TSA (97° vs. 64°, P < .01). SA is a safe, durable procedure in patients with CP to clinically improve pain, function, and satisfaction. RSA was associated with better function and fewer complications than TSA.

Subacromial analgesia via continuous infusion catheter vs. placebo following arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized trials

19-02-2020 – Vincent V.G. An, John E. Farey, Sascha Karunaratne, Christopher J. Smithers, Jeffrey F. Petchell

Journal Article

Subacromial analgesia (SAA) is hypothesized to reduce pain after arthroscopic shoulder surgery by delivering a continuous infusion of local anesthetic directly to the surgical site. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of SAA vs. placebo for pain relief after arthroscopic subacromial shoulder procedures. MEDLINE, Embase, PubMed, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing SAA with placebo after arthroscopic shoulder surgery. Outcomes collected included pain scores (converted to equivalent ordinal visual analog scores; minimal clinically important difference 1.4 cm), oral morphine equivalents used postoperatively, and catheter-related complications. Meta-analysis was performed via a random-effects model. Included trials underwent a risk of bias and quality of evidence assessment. Nine studies involving 459 participants were included. There were no clinically significant changes for pain scores in SAA at 6-, 12-, 24-, and 48-hour postoperative timepoints. Patients receiving SAA used less morphine equivalents of pain medication at 12 hours only (-0.37 mg, 95% confidence interval: -0.63 to -0.11), but there was no significant difference at 24 and 48 hours. There were no major complications (infection or reoperation). Included trials demonstrated a moderate risk-of-bias, and low to very low quality of evidence for primary outcomes. Subacromial continuous infusion of local anesthetic does not provide a clinically significant benefit compared with placebo as part of a multimodal analgesia regime after arthroscopic subacromial surgical procedures. Future, high-quality trials are required to further assess the efficacy of SAA against placebo.

Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial

12-01-2020 – Mats C. Ranebo, Hanna C. Björnsson Hallgren, Theresa Holmgren, Lars E. Adolfsson

Journal Article

Previous randomized trials on cuff repair have included mainly degenerative tears, but studies on acute traumatic tears are lacking. We aimed to compare early surgical repair with nonoperative treatment for traumatic supraspinatus tears. We did a 2-center randomized controlled trial of patients with small rotator cuff tears mainly involving supraspinatus, comparing surgical repair (n = 32) and physiotherapy (n = 26). The primary outcome was a group difference in the Constant-Murley score at 12-month follow-up. Secondary outcomes were differences in the Western Ontario Rotator Cuff index, pain (Numerical Rating Scale 0-10), and Euro quality-of-life-visual analog scale. We used magnetic resonance imaging to assess retear rate, tear progression, fatty infiltration, and atrophy. The mean age was 59.7 years (range, 44-77 years), median sagittal tear size was 9.7 mm (range, 4-21 mm), and baseline characteristics were well balanced between the 2 groups. The repair group had a median Constant-Murley of 83 (25 quartile range [QR]) and the physiotherapy group 78 (QR, 22) at 12 months, with the between-group difference in medians of 4.5 (-5 to 9, 95% confidence interval; P = .68). The corresponding values for the Western Ontario Rotator Cuff index were 91% (QR, 24) vs. 86% (QR, 24), with the between-group difference of 5.0 (-4 to 9, 95% confidence interval; P = .62). There was no difference in Numerical Rating Scale or in Euro quality-of-life-visual analog scale. Retear was found in 6.5% of repaired patients and tear progression >5 mm in 29.2% of unrepaired patients. We found no significant differences in clinical outcomes between cuff repair and nonoperative treatment at 12-month follow-up. Approximately one third of unrepaired patients had a tear enlargement of more than 5 mm.

Prevalence and risk factors for development of subscapularis and biceps pathology in shoulders with degenerative rotator cuff disease: axa0prospective cohort evaluation

19-02-2020 – Siddhant K. Mehta, Sharlene A. Teefey, William Middleton, Karen Steger-May, Julianne A. Sefko, Jay D. Keener

Journal Article

The prevalence of subscapularis and long head of biceps (LHB) in relation to the presence and severity of posterosuperior (PS) rotator cuff disease is not known. Subjects with asymptomatic rotator cuff tears were enrolled for this prospective longitudinal study (n = 354) and followed annually with shoulder ultrasonography and clinical evaluations to assess for the presence of subscapularis, LHB, and PS rotator cuff pathology and pain development. Subscapularis pathology developed in 14% of shoulders over a median follow-up of 5 years, with partial-thickness tearing occurring most commonly (83%). Age, sex, and hand dominance were not associated with subscapularis pathology. A greater proportion of concomitant full-thickness PS cuff tears were observed in shoulders that developed subscapularis tears (76% vs. 50%, P = .002). The PS cuff tear width (10 mm vs. 14 mm, P = .01) at the time of enrollment and both tear width (10 mm vs. 15 mm, P = .003) and length (12 mm vs. 15.5 mm, P = .02) at the time of diagnosis of subscapularis pathology were greater in subscapularis-torn shoulders. LHB pathology was prevalent in 34% of shoulders, with dislocation/subluxation occurring in 63% and higher prevalence in subscapularis-torn shoulders (71% vs. 12%, P < .01). Subscapularis-torn shoulders were more likely to develop pain (67% vs. 45%, P = .004), and concomitant PS cuff tear enlargement was associated with greater risk for pain development (76% vs. 36%, P = .01). The development of subscapularis and LHB pathology is significantly related to the size of the PS cuff tear. Subscapularis involvement is associated with greater risk of pain development in degenerative rotator cuff disease.

A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty

12-01-2020 – Mia S. Hagen, Sachin Allahabadi, Alan L. Zhang, Brian T. Feeley, Trevor Grace, C. Benjamin Ma

Journal Article

Reverse total shoulder arthroplasty (RTSA) does not have a standard postoperative protocol. Although instability is a worrisome complication, prolonged immobilization may also be disabling in the elderly population. This study aimed to determine if early vs. delayed range of motion (ROM) after RTSA affected postoperative ROM, patient-reported outcomes, and the dislocation rate. A single-blinded, randomized controlled trial was performed enrolling patients from 2013 to 2017. Patients were randomly assigned to either a delayed-rehabilitation group (no ROM for 6 weeks) or early-rehabilitation group (immediate physical therapy for passive and active ROM) and followed up for a minimum of 1 year. Demographic characteristics, ROM, American Shoulder and Elbow Surgeons (ASES) scores, and complications were recorded. Of an initial enrollment of 107 shoulders, 80.3% completed 1-year follow-up: 44 shoulders in the delayed-therapy group and 42 shoulders in the immediate-therapy group. Both groups had significantly improved forward flexion (32° improvement) and abduction (22° improvement) by 3 months. Both groups showed significant improvements in ASES scores by 6 weeks (9.4-point improvement in composite score) with continued improvement through 6 months (35.1 points). No significant differences were found between groups for any postoperative measure, with the exception of the ASES functional score favoring the delayed-therapy group at 6 months (26.3-point improvement vs. 16.7-point improvement). No differences in complications, notching, or narcotic use were noted between groups. Both early- and delayed-ROM protocols after RTSA demonstrated significant, similar improvements in ROM and outcomes. Early initiation of postoperative rehabilitation may benefit the elderly population by avoiding the limitations of prolonged immobilization postoperatively.

Response to Van Tongel and De Wilde regarding: “A biomechanical comparison of a novel technique for distal clavicle fracture repair versus locked plating”

19-02-2020 – David A. Porter, Gautam P. Yagnik


JSES Hybrid / Gold Open Access

19-02-2020 – William J. Mallon


Let’s “recall” sensitivity and specificity: Letter to the Editor regarding Gowd etxa0al: “Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty”

19-02-2020 – Mikaël Chelli, Pascal Boileau


Vault perforation after eccentric glenoid reaming for deformity correction in anatomic total shoulder arthroplasty

18-02-2020 – Adam Olszewski, Austin J. Ramme, Tristan Maerz, Michael T. Freehill, John J.P. Warner, Asheesh Bedi

Journal Article

The management of glenoid deformity during anatomic total shoulder arthroplasty remains controversial. In this study, we evaluate variable correction of glenoid deformity by eccentric reaming. We hypothesize that partial correction of modified Walch B/C-type glenoid deformities can achieve 75% bone-implant contact area (BICA) with a reduced vault perforation risk compared with complete correction. Fifty shoulder computed tomographic scans with glenohumeral osteoarthritis were retrospectively evaluated. The Tornier Blue
Print v2.1.5 software simulated 3 eccentric reaming scenarios including no, partial, and complete deformity correction. Each scenario was evaluated at 4 BICAs and using 3 implant fixation types. Three-dimensional surface representations were used to evaluate medialization and vault perforation. The patients had mean glenoid retroversion and inclination of 18.5° and 8.8°, respectively, and mean posterior humeral head subluxation of 76%. With 75% BICA, the 3 fixation types had glenoid vault perforation in 6%-26% and 26%-54% of cases for partial and complete glenoid deformity correction, respectively. The central and posterior-inferior implant components were most likely to perforate across all scenarios. Eccentric reaming for glenoid deformity correction increases the risk of vault perforation. Severe glenoid deformity required increased medialization to achieve 75% BICA. Pegged implants have increased chances of perforation compared with a keeled design; the central and posterior-inferior components were most likely to perforate during deformity correction. Partial deformity correction of modified Walch B/C-type glenoid deformities can achieve 75% BICA while reducing the risk of vault perforation compared with complete correction at the time of anatomic total shoulder arthroplasty.

A retrospective review of revision proximal humeral allograft-prosthetic composite procedures: an analysis of proximal humeral bone stock restoration

18-02-2020 – Taylor Reif, Bradley Schoch, Andre Spiguel, Bassem Elhassan, Thomas Wright, Joaquin Sanchez-Sotelo, Benjamin K. Wilke

Journal Article

Allograft-prosthetic composite (APC) reconstruction of the proximal humerus is a technique for reconstruction of large bone deficits, provides improvement in pain and function, and is thought to restore bone if revision surgery is needed. The purpose of this study was to evaluate the ability of proximal humeral APCs to restore usable bone at the time of revision surgery. Two institutional electronic medical records were reviewed to evaluate proximal humeral APC procedures performed between 1970 and 2018. We identified 115 cases, of which 14 underwent revision for aseptic causes. The indications for revision included nonunion (n = 7), glenohumeral instability (n = 5), and allograft fracture (n = 2). Three categories were used to classify the amount of usable allograft retained at revision surgery: type A, complete allograft retention; type B, partial retention; and type C, no retention. A total of 14 patients (6 male and 8 female patients) underwent revision of the APC reconstruction at a mean of 22.8 months. At revision, allograft retention was classified as type A in 6 shoulders, type B in 3, and type C in 5. Type A cases were associated with nonunion with a well-fixed stem, type B cases were associated with instability and were converted from a hemiarthroplasty to a reverse total shoulder arthroplasty, and type C cases were associated with an allograft fracture or nonunion with a loose humeral component. A substantial number of revisions of proximal humeral APC reconstructions maintain a portion of the allograft bone (64.3%). This study supports the ongoing use of the APC reconstruction technique for large bone deficits.

Soft tissue injury patterns in posteromedial rotatory instability with dislocation compared with posteromedial dislocation of the elbow joint

18-02-2020 – In Hyeok Rhyou, Jung Hyun Lee, Ji-Ho Lee, Kyung Chul Kim, Kee Baek Ahn, Yong Eok Gwon

Journal Article

We sought to determine injury mechanisms and soft tissue injury patterns of dislocation caused by posteromedial rotatory instability (PMRI) and simple posteromedial (PM) dislocation of the elbow joint that appear similar on simple radiographs. In this retrospective case-series study, we reviewed 13 patients with PMRI dislocation and 10 patients with simple PM dislocation. Three-dimensional computed tomography and magnetic resonance imaging were performed in both groups. The ulnar collateral ligament, lateral collateral ligament complex (LCLC), overlying extensor muscle, and locus of bone contusion were identified. The direction of dislocation was categorized into the pure-posterior or PM type by simple radiographs. The LCLC was completely ruptured in both groups. A completely torn ulnar collateral ligament was observed in 3 patients (23%) in the PMRI dislocation group and 9 patients (90%) in the simple PM dislocation group (P = .005). Regarding injury patterns of the LCLC and overlying extensor muscle, the distraction type was found in 10 patients (77%) and the stripping type was found in 3 patients (23%) in the PMRI dislocation group, whereas all patients (100%) in the simple PM dislocation group had the distraction type (P = .103). Bone contusion was observed at the posterolateral olecranon in 2 patients (15%) in the PMRI dislocation group and at the PM olecranon in 4 patients (40%), posterolateral olecranon in 1 (10%), posterior olecranon in 1 (10%), and PM-posterolateral olecranon in 1 (10%) in the simple PM dislocation group (P = .008). In the PMRI dislocation group, 7 patients (54%) had the PM type and 6 (46%) had the pure-posterior type. Simple PM and PMRI dislocations of the elbow joint might have different soft tissue injury characteristics because of different injury mechanisms.

Changes in medial elbow elasticity and joint space gapping during maximal gripping: reliability and validity in evaluation of the medial elbow joint using ultrasound elastography

18-02-2020 – Hiroshi Hattori, Kiyokazu Akasaka, Takahiro Otsudo, Toby Hall, Katsuya Amemiya, Yoshihisa Mori, Katsunobu Sakaguchi, Yomei Tachibana

Journal Article

Medial elbow injuries are common in baseball pitchers. This study investigated the reliability of medial elbow elastography measurement and the characteristics of the medial elbow stabilizers. Medial elbow joint space gapping and the strain ratios of the ulnar collateral ligament (UCL) and the forearm flexor-pronator muscle (FPM) were measured at rest and during gripping in 29 healthy college students. The intraclass correlation coefficients of elastography were calculated. The data were compared between tissues and between rest and gripping. The intraclass correlation coefficients (ICC Elastography measurements of the UCL and FPM have almost perfect reliability. Gripping reduces medial elbow joint space gapping compared with rest. For both tissues, gripping reduces their elasticity compared with rest. The elasticity of the UCL is less than that of the FPM both at rest and during gripping.

Type E2 glenoid bone loss orientation and management with augmented implants

18-02-2020 – Sejla Abdic, Nikolas K. Knowles, Gilles Walch, James A. Johnson, George S. Athwal

Journal Article

The purpose of this study was 2-fold: (1) to quantify type E2 bone loss orientation and its association with rotator cuff fatty infiltration and (2) to examine reverse baseplate designs used to manage type E2 glenoids. Computed tomography scans of 40 patients with type E2 glenoids were examined for pathoanatomic features and erosion orientation. The rotator cuff fatty infiltration grade was compared with the erosion orientation angle. To compare reconstructive options in light of the pathoanatomic findings, virtual implantation of 4 glenoid baseplate designs (standard, half wedge, full wedge, and patient-matched) was conducted to determine the volume of bone removal for seating and impingement-free range of motion. The mean type E2 erosion orientation angle was 47° ± 17° from the 0° superoinferior glenoid axis, resulting in the average erosion being located in the posterosuperior quadrant directed toward the 10:30 clock-face position. The type E2 neoglenoid, on average, involved 67% of the total glenoid surface (total surface area, 946 ± 209 mm The average type E2 erosion orientation was directed toward the 10:30 clock-face position in the posterosuperior glenoid quadrant. This orientation resulted in the patient-matched glenoid augmentation requiring the least amount of bone removal for seating, followed by the full-wedge, half-wedge, and standard designs. Implant selection also substantially affected computationally derived range of motion in external rotation, flexion, extension, and adduction.

Arthroscopic débridement has similar 30-day complications compared with open arthrotomy for the treatment of native shoulder septic arthritis: a population-based study

15-02-2020 – Zain M. Khazi, William T. Cates, Alan G. Shamrock, Qiang An, Kyle R. Duchman, Robert W. Westermann, Brian R. Wolf

Journal Article

This study aimed to determine whether there are significant differences in 30-day perioperative complications between arthroscopic and open débridement (irrigation and débridement [I&D]) for septic arthritis (SA) of the shoulder using the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing arthroscopic or open I&D of the native shoulder from 2006-2016 were identified in the National Surgical Quality Improvement Program database. Those with a diagnosis of SA were included in the study. Patients with a concurrent diagnosis of osteomyelitis around shoulder (n = 25) or polyarthritis (n = 2) were excluded from the study. Patient demographics, comorbidities, and complications were compared between the groups. Poisson regression, which controlled for age and American Society of Anesthesiologists (ASA) score, was used to calculate the relative risks with 95% confidence intervals for minor adverse events, serious adverse events, total adverse events, and unplanned reoperations between the 2 treatment groups, with significance set at P < .0125 after Bonferroni correction. Overall, 147 and 57 patients underwent arthroscopic and open I&D, respectively, for SA of the shoulder. Patients in the open I&D group were more likely to be smokers (P = .0213), whereas patients in the arthroscopy group had higher ASA scores (P = .0008). After controlling for age and ASA score, we found no significant differences in the risk of minor adverse events (P = .0995), serious adverse events (P = .2241), total adverse events (P = .1871), or unplanned reoperations (P = .3855). Arthroscopic débridement appears to be a safe alternative to open débridement for SA of the native shoulder. The incidence and risk of 30-day perioperative complications are similar after arthroscopic and open I&D for SA of the shoulder.

Coracoid morphology is not associated with subscapularis tears

15-02-2020 – Viktor C. Tollemar, Jianhua Wang, Jason L. Koh, Michael J. Lee, Lewis L. Shi

Journal Article

The observation of the roller-wringer effect fueled the idea that coracoid morphology is related to subscapularis pathology. We aimed to examine this relationship, specifically focusing on how the coracohumeral distance (CHD) and 2 new metrics of coracoid morphology relate to subscapularis tears. In this retrospective study, we identified consecutive patients 45 years or older who underwent shoulder arthroscopy for any indication. We blindly reviewed preoperative magnetic resonance imaging studies of each patient, measuring the CHD, lateral extent (LE), and caudal extent (CE) of the coracoid process. Patients’ subscapularis condition was assessed via operative reports; stratified according to Lafosse grade criteria; and compared for differences in the CHD, LE, and CE by 1-way analysis of variance and 2-tailed t tests. The study included 201 patients. Of these, 112 had no evidence of subscapularis injury, whereas Lafosse grade I injuries were identified in 52 patients; grade II, in 19; and grades III-V, in 18. The CHD, LE, and CE were not correlated with subscapularis injury (CHD, P = .36; LE, P = .36; and CE, P = .13). We found no correlation between subscapularis injury and the CHD, LE, and CE. These findings support the idea that coracoid morphology may not be a cause of subscapularis pathology and suggest that coracoplasty may not be necessary prophylactically or as part of subscapularis repair.

High rate of maintaining self-dependence and low complication rate with a new treatment algorithm for proximal humeral fractures in the elderly population

15-02-2020 – Daniel Rikli, Sandra Feissli, Andreas M. Müller, Amir Steinitz, Norbert Suhm, Marcel Jakob, Laurent Audigé

Journal Article

We modified our treatment algorithm for proximal humeral fractures in elderly patients in 2013 to a more conservative approach avoiding locking plates. This study assesses the impact of this change on patient self-dependence. We carried out an observational comparative study including both retrospectively and prospectively collected data. For the former, 147 isolated proximal humeral fracture patients older than 65 years were treated between 2011 and 2013 at our hospital and included in a historical group. The revised treatment algorithm was applied in a similar non-concurrent, comparative patient group (n = 160) prospectively enrolled between 2015 and 2017. The primary outcome was any loss of self-dependence, with secondary outcomes including documentation of shoulder functional scores, quality of life, and adverse events. Historical and prospective patients had similar baseline characteristics. Nonoperative treatment was performed in 53 historical patients (36%) and 83 prospective patients (78%). Prospective patients were 1.6 times less likely to lose some level of self-dependence (risk ratio, 0.62; 95% confidence interval, 0.25-1.5; P = .292), and the local adverse event risk dropped from 12.2% to 5.7% (P = .078). Mean shoulder function and quality of life were similar between the 2 groups. By applying our revised algorithm, a higher proportion of elderly patients maintained their premorbid level of self-dependence and returned to their previous social environment.

Effect of ulnar angulation and soft tissue sectioning on radial head stability in anterior Monteggia injuries: an in vitro biomechanical study

12-02-2020 – Armin Badre, David T. Axford, Clare E. Padmore, Carolyn Berkmortel, Kenneth J. Faber, James A. Johnson, Graham J.W. King

Journal Article

Radial head instability continues to be a challenge in the management of anterior Monteggia injuries; however, there is a paucity of literature on the factors that contribute to this instability. The aim of this biomechanical investigation was to examine the effects of ulnar angulation and soft tissue insufficiency on radial head stability in anterior Monteggia injuries. Six cadaveric arms were mounted in an elbow motion simulator. Radial head translation was measured during simulated active elbow flexion with the forearm supinated. After testing the elbows in the intact state, the ulna was osteotomized and tested at 0°, 10°, 20°, and 30° of extension angulation. To examine the effect of soft tissue insufficiency, the anterior radiocapitellar joint capsule, annular ligament, quadrate ligament, and the proximal and middle interosseous membrane (IOM) were sequentially sectioned. There was a significant increase in anterior radial head translation with greater ulnar extension angulation. Sequential soft tissue sectioning also significantly increased anterior radial head translation. There was no increase in radial head translation with isolated sectioning of the anterior radiocapitellar joint capsule. Additional sectioning of the annular ligament and quadrate ligament slightly increased anterior radial head translation but did not reach statistical significance. Subsequent sectioning of the proximal and middle IOM resulted in significant increases in anterior radial head translation. Our study demonstrates that progressive ulnar extension angulation results in an incremental increase in anterior radial head translation in anterior Monteggia injuries. Moreover, increasing magnitudes of soft tissue disruption result in greater anterior radial head instability.

Reverse shoulder arthroplasty in patients younger than 65 years, minimum 5-year follow-up

12-02-2020 – Joseph G. Monir, Dilhan Abeyewardene, Joseph J. King, Thomas W. Wright, Bradley S. Schoch

Journal Article

Indications for reverse total shoulder arthroplasty (RTSA) are expanding, and more young patients are undergoing RTSA. Younger patients are expected to place increased functional demands on their shoulder, which may affect implant performance and longevity. Reports on longer-term outcomes in young patients remain limited. This study evaluates the minimum 5-year functional outcomes of RTSA in patients younger than 65 years. A retrospective review was performed using a multinational prospective shoulder arthroplasty database of a single implant system, Exactech Equinoxe (Gainesville, FL, USA). All RTSAs performed between 2007 and 2014 in patients younger than 65 years with minimum 5-year follow-up were included. Shoulder function was assessed preoperatively and at last follow-up via range-of-motion measurements and multiple patient-reported outcome measures. Fifty-two shoulders were evaluated at an average follow-up of 6.3 years. Abduction, forward flexion, internal rotation, and Simple Shoulder Test, Constant, American Shoulder and Elbow Surgeons, University of California-Los Angeles, Shoulder Pain and Disability Index, and visual analog scale scores all showed statistically significant improvements greater than the minimum clinically important difference at the time of last follow-up. Three patients (5.8%) required revision surgery after a mean of 7.5 years and 1 more suffered an acromial stress fracture, bringing the total complication rate to 7.7%. Five patients (9.6%) demonstrated scapular notching, one of whom required revision arthroplasty. RTSA provides clinically significant improvement in nearly all functional measures at a mean follow-up of 6.3 years in patients younger than 65 years. The implants appear to have good midterm survivorship; only 5.8% of patients required revision.

The natural course of and risk factors for tear progression in conservatively treated full-thickness rotator cuff tears

12-02-2020 – Whanik Jung, Sanguk Lee, Sae Hoon Kim

Journal Article

The natural course of and risk factors for tear progression in full-thickness rotator cuff tears (FTRCTs) have not been clarified yet. The study’s purpose was to retrospectively evaluate tear progression in FTRCTs by using magnetic resonance imaging (MRI) and to identify risk factors that are relevant to such tear progression. Between June 2010 and September 2019, a total of 345 patients with FTRCTs who had been diagnosed via MRI were treated conservatively. Of these, 48 patients who underwent post-treatment follow-up MRI were retrospectively enrolled. Tear progression was defined as significant when the tear size increased by >5 mm. The mean MRI follow-up duration was 22 ± 14 months (range, 12-65 months). Among the 48 patients (mean age, 69 years; range, 53-81), 26 (54%) and 20 (41%) showed medial-lateral (M-L) and anterior-posterior (A-P) tear progression on MRI follow-up. Multivariate analysis revealed that MRI follow-up duration (P = .011), diabetes mellitus (P = .017), and infraspinatus muscle atrophy (P = .011) were independent risk factors for tear progression in the A-P plane. A high critical shoulder angle (P = .011) and supraspinatus (P = .024) and infraspinatus (P = .020) muscle atrophy were risk factors associated with M-L tear progression. Among the assessed patients, a considerable number of FTRCTs increased in size during the follow-up period. Severe infraspinatus muscle atrophy was the independent risk factor for exacerbation of A-P and M-L tear progression.

Primary reverse shoulder arthroplasty: how did medialized and glenoid-based lateralized style prostheses compare at 10 years?

12-02-2020 – Justin C. Kennon, Chad Songy, Douglas Bartels, Joseph Statz, Robert H. Cofield, John W. Sperling, Joaquin Sanchez-Sotelo

Journal Article

The purpose of this study was to compare long-term outcomes, complications, and reoperation rates of primary reverse total shoulder arthroplasty (RTSA) performed at a single institution using 2 implant designs: a Grammont medialized prosthesis (medialized [M] group) and a Frankle glenoid-based lateralized prosthesis (glenoid-lateralized [GL] group). Between 2004 and 2008, 100 consecutive single-institution primary RTSAs were performed by reconstructive shoulder surgeons who were not design consultants, with the aim of obtaining 10-year follow-up: 56 in the M group and 44 in the GL group. Patients were followed up until death, until revision surgery, or for a minimum of 10 years. Of 100 patients, 87 had more than 2 years’ follow-up (mean, 77 months). A subset analysis of 41 patients with an average of 10.2 years’ follow-up showed sustained long-term outcomes. RTSA provided clinical improvements without significant differences between the M and GL groups, except for improved active forward elevation in the M group (144° in M group vs. 115° in GL group, P = .002). Reoperation was required in 6 shoulders (10-year cumulative incidence of 3 [5%] in M group vs. 3 [8%] in GL group) for a total of 16 complications (10-year cumulative incidence of 8 [14%] in M group vs. 8 [20%] in GL group). Notching rates were significantly higher in the M group (77% in M group vs. 47% in GL group, P = .013); differences in severe notching (grade 3 or 4) were clinically relevant but did not reach statistical significance (23% in M group vs. 9% in GL group, P = .22). Primary RTSA using these first 2 prosthesis designs was associated with good outcomes and low reoperation (5%-8%) and complication (14%-20%) rates at 10 years. The M group had higher rates of notching. These results may provide a benchmark for comparison with newer implants, especially considering that these results include the early RTSA implantation learning curve.

Lower operating volume in shoulder arthroplasty is associated with increased revision rates in the early postoperative period: long-term analysis from the Australian Orthopaedic Association National Joint Replacement Registry

12-02-2020 – Jamie S. Brown, Robert J. Gordon, Yi Peng, Alesha Hatton, Richard S. Page, Kelly A. Macgroarty

Journal Article

Improved short-term outcomes have been demonstrated with higher surgical volume in shoulder arthroplasty. There is however, little data regarding long-term outcomes. Revision data from the Australian Orthopaedic Association National Joint Replacement Registry from 2004-2017 was analyzed according to 3 selected surgeon volume thresholds: 20 shoulder arthroplasty cases per surgeon, per year. There was a significantly higher rate of revision for stemmed total shoulder arthroplasty (TSA) for osteoarthritis (OA) for the 20/yr group for the first 1.5 years only (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.71, P = .009). For reverse total shoulder arthroplasty (r
TSA) performed for OA, there was a higher revision rate for the 20/yr group for the first 3 months only (HR 2.58, 95% CI 1.67-3.97, P < .001). In r
TSA for cuff arthropathy, there was a significantly higher rate of revision for the 20/yr group throughout the follow-up period (HR 1.66, 95% CI 1.21-2.28, P = .001). There was no significant difference for the primary diagnosis of fracture. Lower surgical volume was associated with higher all-cause revision rates in the early postoperative period in TSA and r
TSA for OA and throughout the follow-up period in r
TSA for cuff arthropathy. Despite increases in the volume of shoulder arthroplasties performed in recent years, more than 78% of surgeons undertake fewer than 10 procedures per year.

Surgical treatment for long head of the biceps tendinopathy: a network meta-analysis

11-02-2020 – Utkarsh Anil, Eoghan T. Hurley, Matthew T. Kingery, Leo Pauzenberger, Hannan Mullett, Eric J. Strauss

Journal Article

Surgical options for pathology affecting the long head of the biceps tendon (LHBT) include tenotomy and tenodesis, both of which can be performed with a variety of fixation methods. This study aimed to compare surgical treatment options for LHBT lesions using a network meta-analysis of published clinical studies. A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Clinical studies comparing surgical treatment options for LHBT lesions were included. Postoperative outcomes were compared between surgical treatment options using a frequentist approach to network meta-analysis. There were 22 studies comparing surgical treatment options for LHBT pathology including arthroscopic tenotomy, arthroscopic suprapectoral tenodesis, arthroscopic intracuff tenodesis, and open subpectoral tenodesis, consisting of 1804 patients. Compared with arthroscopic tenotomy, open subpectoral tenodesis resulted in a significantly greater American Shoulder and Elbow Surgeons score (mean difference, 4.58; P = .014). On the basis of the P-score, all 3 tenodesis techniques ranked above tenotomy with respect to the Constant score. Compared with arthroscopic tenotomy, the incidence of Popeye deformity was reduced with arthroscopic suprapectoral tenodesis (odds ratio [OR], 0.23; P < .001) and open subpectoral tenodesis (OR, 0.25; P = .022). The incidence of bicipital groove pain was increased after arthroscopic intracuff tenodesis (OR, 2.89; P = .021) compared with arthroscopic tenotomy. Lesions of the LHBT treated with open or arthroscopic tenodesis resulted in comparatively superior functional outcomes and a lower incidence of Popeye deformity, whereas arthroscopic intracuff tenodesis resulted in a higher incidence of bicipital groove pain.

Outpatient vs. inpatient reverse total shoulder arthroplasty: outcomes and complications

10-02-2020 – Brandon J. Erickson, Yousef Shishani, Stacy Jones, Tia Sinclair, Justin Griffin, Anthony A. Romeo, Reuben Gobezie

Journal Article

Reverse total shoulder arthroplasty (RTSA) is an effective treatment option for many shoulder conditions. Historically, this surgical procedure was performed on an inpatient basis. There has been a recent trend to perform RTSA on an outpatient basis in proper candidates. All patients who underwent outpatient RTSA performed by a single surgeon between 2015 and 2017 were included. Demographic information and clinical outcome scores (American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores), as well as data on complications, readmission, and revision surgery, were recorded. This group of patients was then compared with a cohort of patients who underwent RTSA in the inpatient setting during the same period. Overall, 241 patients (average age, 68.9 years; 52.3% female patients) underwent outpatient RTSA and were included. Patients who underwent outpatient RTSA showed significant improvements in all clinical outcome scores at both 1 and 2 year postoperatively (all P < .0001). The control group of patients who underwent RTSA as inpatients consisted of 373 patients (average age, 72 years; 66% female patients). Significantly more controls had diabetes (P = .007), and controls had a higher body mass index (P = .022). No significant differences existed in improvements in clinical outcome scores between the inpatient and outpatient groups. Complication rates were significantly lower for outpatient cases than for inpatient controls (7.0% vs. 12.7%, P = .023). RTSA performed in an outpatient setting is a safe and reliable procedure that provides significant improvements in clinical outcome scores with fewer complications compared with inpatient RTSA.

Is there a difference in the acromiohumeral distances measured on radiographic and magnetic resonance images of the same shoulder with a massive rotator cuff tear?

10-02-2020 – Raffy Mirzayan, Steven Donohoe, Michael Batech, Brian D. Suh, Daniel C. Acevedo, Anshuman Singh

Journal Article

The purpose of our study was to compare the acromiohumeral distance (AHD) between radiographic and magnetic resonance images (MRIs) of the same shoulder with massive rotator cuff tears (MRCTs). Thirty-four shoulders with MRCTs that had an MRI and radiograph of the same shoulder within an average of 40.3 days (range: 8-109 days) were identified. AHD was measured digitally on radiograph and MRI by 3 examiners. Shoulders were grouped into Hamada grades <3 (group 1) and Hamada grades ≥3 (group 2). The mean age was 66.4 years (range: 51-89). There were 19 men (59%). The Kappa for inter-rater reliability was 0.982 (95% confidence interval [CI] 0.975, 0.988) for radiographs and 0.88 (95% CI 0.75, 0.94) for MRI. There was a significant difference in the mean AHD of group 1 on radiograph vs. MRI (7.9 mm vs. 2.5 mm, respectively; P < .0001), but no difference in group 2 (1.8 mm vs. 2.2 mm, respectively; P = .45). There was no difference in AHD in group 1 between shoulders with Goutallier stage <3 (8.1 ± 1.9 mm) and those with Goutallier stage ≥3 (7.3 ± 2.1 mm) (P = .3479). There was no difference in AHD in group 2 between shoulders with Goutallier stage <3 (3.0 ± 0.1 mm) and those with Goutallier stage ≥3 (1.5 ± 1.0 mm) (P = .079). There is a significant difference in AHD measurements between radiograph and MRI of the same shoulder with MRCT in early Hamada grades. AHDs measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures.

Effect of preoperative teres minor hypertrophy on reverse total shoulder arthroplasty

10-02-2020 – Young Hoon Jang, Dong Ook Kim, Sae Hoon Kim

Journal Article

The preoperative status of the teres minor (Tm) can affect the outcome of reverse total shoulder arthroplasty (RTSA). The effect of preoperative Tm hypertrophy on the outcome of RTSA is unclear. A total of 86 shoulders that underwent RTSA were retrospectively enrolled. Of these, 48 cases with a Tm occupation ratio (OR) of >0.288 in the preoperative magnetic resonance image were assigned to the hypertrophic group, and 38 cases to the control group. The two groups were compared with respect to preoperative rotator cuff tear involvement, fatty infiltration, pre- and postoperative rotator cuff ORs, pain scores, functional scores, range of motion, and muscle strength. Postoperative Tm ORs in 1-year follow-up multidetector computed tomography were compared with preoperative Tm ORs. Preoperatively, integrities of infraspinatus (ISP) and supraspinatus were significantly different between the 2 groups (P = .001, 0.009, each). Preoperative ISP ORs were significantly related to preoperative Tm ORs (r = -0.534, P < .001). The mean pre- to postoperative change of Tm ORs in the hypertrophic group decreased (-0.029 ± 0.068), whereas that of the control group increased (+0.047 ± 0.092). Postoperative pain scores, functional scores, range of motion, and muscle strength were not different between groups. In cases of advanced rotator cuff tear requiring RTSA, Tm hypertrophy is found to be related to tear and atrophy of the ISP, suggesting that Tm hypertrophy is a compensatory change for ISP dysfunction. However, Tm hypertrophy was observed to diminish after RTSA. Preoperative Tm hypertrophy appears to have no beneficial effect on the outcomes of RTSA.

The clinical and radiologicxa0outcome of microfracture on arthroscopic repair for full-thickness rotator cuff tear

17-09-2019 – Anil Pulatkan, Wasim Anwar, Sevil Tokdemir, Sercan Akpinar, Kerem Bilsel

Journal Article

The persistent incidence of retear despite improvements in techniques led orthopedic surgeons to the application of principles of tissue bioengineering to achieve enhanced repair and functional outcomes. The purpose of this study was to compare clinical and radiologic outcomes of arthroscopic single-row repair augmented with microfracture (SRM) at the greater tuberosity with single-row (SR) and double-row (DR) repair in the treatment of full-thickness rotator cuff tears. This is a retrospective comparative study. A total of 123 patients were enrolled for arthroscopic repair of full-thickness rotator cuff tears, with 40 patients treated by SR, 44 by SRM, and 39 by DR. The minimum follow-up was 2 years. The primary outcome was retear rate, which was detected by magnetic resonance imaging, and the secondary outcome was functional outcome. The mean age of the patients was 59.2 years, 58.1 years, and 60.6 years in the SR, SRM, and DR groups, respectively. The retear rate was 33%, 14%, and 36% in the SR, SRM, and DR groups, respectively (P = .045). The SRM group had significantly improved functional outcomes compared with the SR and DR groups in terms of the postoperative Constant score and visual analog scale score (P = .001 and .002, respectively). Delta Constant scores were nonsignificant for retear and intact tendons (P = .137). SRM has a significantly lower retear rate and better functional outcome than SR and DR repair.

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.

Risk factors for opioid use after total shoulder arthroplasty

10-09-2019 – Zain M. Khazi, Yining Lu, Bhavik H. Patel, Jourdan M. Cancienne, Brian Werner, Brian Forsythe

Journal Article

The purpose was to assess opioid use before and after anatomic and reverse total shoulder arthroplasty (TSA) and determine patient factors associated with prolonged postoperative opioid use. Patients undergoing primary TSA (anatomic or reverse) were identified within the Humana database from 2007 to 2015. Patients were categorized as opioid-naive patients who did not fill a prescription prior to surgery or those who filled opioid prescriptions within 3 months preoperatively (OU); the OU cohort was subdivided into those filling opioid prescriptions within 1 month preoperatively and those filling opioid prescriptions between 1 and 3 months preoperatively. The incidence of opioid use was evaluated preoperatively and longitudinally tracked for each cohort. Multivariate analysis was used to identify factors associated with opioid use at 12 months after surgery, with statistical significance defined as P < .05. Overall, 12,038 patients (5180 in OU cohort, 43%) underwent primary TSA during the study period. Opioid use declined after the first postoperative month; however, the incidence of opioid use was significantly higher in the OU cohort than in the opioid-naive cohort at 1 year (31.4% vs. 3.1%, P < .0001). Subgroup analysis revealed a similar decline in postoperative opioid use for anatomic and reverse TSA (P < .0001 for both). Multivariate analysis identified chronic preoperative opioid use (ie, filling an opioid prescription between 1 and 3 months prior to surgery) as the strongest risk factor for opioid use at 12 months after anatomic and reverse TSA (P < .0001). More than 40% of patients undergoing TSA received opioid medications within 3 months before surgery. Preoperative opioid use, age younger than 65 years, and fibromyalgia were independent risk factors for opioid use 1 year following anatomic and reverse TSA. Chronic preoperative opioid use conferred the highest risk of prolonged postoperative opioid use.

A randomized controlled trial comparing subscapularis tenotomy with peel in anatomic shoulder arthroplasty

30-11-2019 – Peter Lapner, J Whitcomb Pollock, Tinghua Zhang, Sara Ruggiero, Franco Momoli, Adnan Sheikh, George S. Athwal

Journal Article

Controversy exists regarding the optimal technique of subscapularis tendon mobilization during anatomic shoulder arthroplasty. The purpose of this prospective, randomized, double-blind study was to compare internal rotation strength in the belly-press position and functional outcomes between the subscapularis tenotomy and subscapularis peel approaches during shoulder arthroplasty. Patients undergoing anatomic shoulder arthroplasty were randomized to either a tenotomy or peel approach. The primary outcome was internal rotation strength in the belly-press position, measured by an electronic handheld dynamometer at 24 months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons (ASES) score, range of motion, radiographic lucencies, and adverse events. We randomized 100 patients to subscapularis tenotomy (n = 47) or peel (n = 53). Eighty-one percent of the cohort returned for 24 months’ follow-up. Compared with baseline measures, mean internal rotation strength in the belly-press position and WOOS and ASES scores improved in both groups at final follow-up (P < .0001). Intention-to-treat analysis for internal rotation strength at 24 months revealed no significant difference (P = .57) between tenotomy (mean, 4.9 kg; SD, 3.8 kg) and peel (mean, 5.4 kg; SD, 3.9 kg). Comparison of WOOS and ASES scores demonstrated no significant differences between groups at any time point. The healing rates by ultrasound were 72% for tenotomy and 71% for peel (P = .99). No statistically significant difference in internal rotation strength was identified between the tenotomy and peel groups. The secondary outcomes were not significantly different between groups.

Can small glenospheres with eccentricity reduce scapular notching as effectively as large glenospheres without eccentricity? A prospective randomized study

01-12-2019 – Carlos Torrens, Joan Miquel, Raquel Martínez, Fernando Santana

Journal Article

The objective of this study was to analyze whether small glenospheres with eccentricity were comparable to large glenospheres in scapular notch development. This prospective randomized study included 82 patients who had undergone a reverse shoulder arthroplasty with a 2-year follow-up period. After randomization, 43 patients were allocated to receive a 42-mm glenosphere and 39 patients were allocated to receive a 38-mm glenosphere with 2 mm of eccentricity. Scapular notch development was defined after examination of an anteroposterior radiograph at the end of follow-up. Functional outcomes were recorded using the Constant score before surgery and at the end of follow-up. Scapular notch development was present in 16.6% of patients who received a 42-mm glenosphere and 34.2% of patients who received a 38-mm eccentric glenosphere. No significant difference was found between the groups with the number of cases available (P = .07). Functional outcomes significantly increased from preoperatively to postoperatively in both groups, with no significant difference found between them (P = .77). The mean glenosphere overhang measure was 6.3 mm in patients with a 42-mm glenosphere and 6.0 mm in those with a 38-mm eccentric glenosphere (P = .68). No significant differences were noted between patients with a scapular notch and patients without a scapular notch in terms of functional outcomes. Small glenospheres with eccentricity fared slightly worse than large glenospheres regarding scapular notch development, even though no significant differences were noted. Functional outcomes were comparable between the 2 designs.

Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes–positive culture rate in shoulder surgery: a prospective randomized controlled trial

17-12-2019 – Justin D. Stull, Thema A. Nicholson, Daniel E. Davis, Surena Namdari

Journal Article

Hydrogen peroxide is an inexpensive and effective antimicrobial agent that can be implemented in surgical skin preparations. The purpose of this study was to evaluate the decolonization effect of Cutibacterium acnes when adding hydrogen peroxide to a standard sterile preparation for shoulder surgery. This was a single-institution, prospective, randomized controlled trial of male patients undergoing shoulder arthroscopy (April 2018 and May 2019). Patients were randomized to a standard skin preparation vs. an additional sterile preparation with 3% hydrogen peroxide. After draping, a 3-mm punch biopsy was obtained from the posterior arthroscopic portal site of all patients. Anaerobic and aerobic culture substrates were used and held for 13 days. Seventy male patients were randomized into the hydrogen peroxide group and 70 male patients were in the traditional group. Twelve (17.1%) patients in the hydrogen peroxide group and 24 (34.2%) patients in the traditional group had positive cultures for C acnes (P = .033). Cultures were positive at a mean of 4.5 days (range 3-7) in the hydrogen peroxide group and 4.1 days (range 3-8) in the traditional group (P = .48). There were no cases of skin reaction to the surgical preparation in either group. The results of this study suggest that the addition of hydrogen peroxide to preoperative surgical site preparation can reduce the C acnes culture rate. Hydrogen peroxide is inexpensive and can be added to the typical skin preparation used prior to shoulder surgery without substantial risk of skin reactions.

JSES expanded abstracts

19-01-2020 – William J. Mallon


Erratum to: “Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy” J Shoulder Elbow Surg 2018;28:1942-1947

19-01-2020 –

Published Erratum

Brachial plexus palsy after clavicle fracture: 3xa0cases

01-12-2019 – Tomohiro Saito, Tomohiro Matusmura, Katsushi Takeshita

Journal Article

Brachial plexus palsy after clavicle fracture is extremely rare. We experienced 3 cases of brachial plexus palsy after clavicle fracture and investigated the findings that such patients have in common and the clinical results of these cases. We retrospectively analyzed the data of 3 patients with clavicle fracture who had no neurovascular symptoms at the time of the initial injury but gradually developed brachial plexus palsy within 1 month after the injury. The patients were aged 70, 62, and 68 years; 2 patients were male and 1 was female. The patients’ backgrounds and clinical results were assessed. All patients had a displaced middle-third clavicle fracture and underwent conservative therapy with a figure-8 bandage. The intervals between fracture and symptoms of brachial plexus palsy were 8, 30, and 14 days. The times from symptoms of brachial plexus palsy to surgery were 27, 75, and 28 days. In all patients, surgery revealed a ruptured subclavius muscle and abnormal development of granulation tissue around the fracture site, compressing the brachial plexus. Open reduction and plate fixation was performed in 2 patients, and clavicle resection was performed in 1 patient. The intervals between surgery and full recovery of muscle strength were 11, 6, and 6 months. The findings our 3 patients with brachial plexus palsy after clavicle fracture had in common are old age, middle-third displaced clavicle fracture, and abnormal development of granulation tissue around the fracture site. Surgical intervention yielded good clinical outcomes.

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

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

Journal Article

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

Lower-extremity total joint arthroplastyxa0in shoulder arthroplasty patients: does the order of the lower-extremity total joint arthroplasty matter?

16-09-2019 – Heather A. Prentice, Priscilla H. Chan, Mark T. Dillon, Nithin C. Reddy, Ronald A. Navarro, Elizabeth W. Paxton

Journal Article

As total joint arthroplasty (TJA) utilization increases, arthroplasties of multiple joints in a patient are more common. An understanding of the success of shoulder arthroplasty patients also requiring a lower-extremity (hip or knee) TJA is lacking. We evaluated the following questions: (1) Is there a difference in the revision risk following shoulder arthroplasty in patients who also undergo a lower-extremity TJA compared with those who do not? (2) Does the revision risk differ depending on the sequence of the procedures? Patients who underwent elective primary shoulder arthroplasty from 2009 through 2015 were identified using Kaiser Permanente’s shoulder arthroplasty registry. Patients with a lower-extremity TJA were identified using the institution’s total joint replacement registry. Revision related to the index shoulder was modeled via Cox regression stratified by procedure type and adjusted for confounders. Of the 4751 shoulder arthroplasties identified, 1285 (27.0%) underwent a prior hip and/or knee arthroplasty and 483 (10.2%) underwent a hip and/or knee arthroplasty following the index shoulder arthroplasty. No difference was found in all-cause shoulder revision risk with lower-extremity TJA before (hazard ratio, 1.38; 95% confidence interval, 0.97-1.96) or after (hazard ratio, 1.30; 95% confidence interval, 0.82-2.06) the index shoulder arthroplasty compared with patients who underwent a shoulder arthroplasty only. In our study sample, we did not observe shoulder revision surgery risk to be different in patients who also underwent a lower-extremity TJA, regardless of the sequence of the 2 procedures. Future prospective studies should investigate whether the timing of the lower-extremity TJA in relation to the shoulder procedure impacts the latter’s success.

The backward traction test: a new and effective test for diagnosis of biceps and pulley lesions

19-09-2019 – Danmei Li, Weiming Wang, Yupeng Liu, Xiaojun Ma, Shibo Huang, Zhenan Qu

Journal Article

The value of physical examination for diagnosis of lesions of the long head of the biceps (LHB) and the pulley remains unsatisfactory. The purpose of this study was to describe a new diagnostic test, the backward traction (BT) test, to detect lesions of the LHB and the biceps pulley. A prospective study of 143 patients was performed to evaluate the diagnostic value of the BT test and 2 traditional clinical tests (Speed and Yergason tests). Shoulder arthroscopy was used as the “gold standard.” For the detection of LHB injury, the BT test was the most sensitive (74%) and accurate (68%). The BT test had a higher diagnostic value for pulley lesions, with a high sensitivity of 81% and an accuracy of 71%. No significant differences in terms of specificity for LHB and pulley lesions were observed between tests. Regarding pulley lesions, the internally rotated and externally rotated BT test positions had high specificity for the diagnosis of specific anteromedial and posterolateral pulley lesions (79% and 73%, respectively). The BT test had a high κ coefficient of 0.768-0.811. The BT test is more sensitive and accurate as a new test for LHB and pulley lesions and also specific to distinguish the medial sling and lateral sling lesions of the pulley.

RETRACTED: Clinical and functional impairment after nonoperative treatment of distal biceps ruptures

19-01-2020 – Christopher C. Schmidt, Brandon T. Brown, Daniel L. Schmidt, Michael P. Smolinski, Thomas Kotsonis, Kenneth J. Faber, Kraig S. Graham, Tyler J. Madonna, Patrick J. Smolinski, Mark Carl Miller

Published Erratum

Treatment of elbow periprosthetic joint infection: a systematic review of clinical outcomes

19-01-2020 – Michael J. Gutman, Michael A. Stone, Surena Namdari, Joseph A. Abboud

Journal Article

Periprosthetic joint infection (PJI) of the elbow is a relatively common complication after total elbow arthroplasty (TEA), and its treatment is frequently variable. Few articles have provided direct comparisons of outcomes, making it difficult to draw conclusions from the available literature. This systematic review synthesizes the English-language literature on elbow PJI to quantify treatment outcomes. The PubMed and Scopus databases were searched in December 2018. Our review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Keywords included “elbow replacement infection” and “elbow arthroplasty infection.” A total of 1056 titles were identified; after application of the exclusion criteria, 41 studies met the screening criteria and underwent full-text review. Fifteen articles were included for the final analysis regarding demographic characteristics, risk factors, infecting organisms, success of eradication of infection based on surgical method, and functional outcomes of specific treatment regimens. Among the 15 articles selected, there were 309 TEA infections. Staphylococcus aureus was the most frequently isolated organism (42.4%), followed by coagulase-negative staphylococci (32.6%). Risk factors for the development of elbow PJI included rheumatoid arthritis, steroid use, an immunocompromised state, and previous elbow surgery. The rate of successful infection eradication was highest with 2-stage revision (81.2%) and lowest with irrigation and débridement for component retention (55.8%). The level of evidence was IV in 14 studies and III in 1 study. In this systematic review of TEA infections, Staphylococcus species represent the most common infecting organism. Two-stage revision was the most effective treatment for elbow PJI, showing the lowest recurrence rate for infection.

Os acromiale: systematic review of surgical outcomes

03-09-2019 – Gean C. Viner, Jun Kit He, Eugene W. Brabston, Amit Momaya, Brent A. Ponce

Journal Article

The literature is unclear as to the optimal surgical management of a symptomatic os acromiale that has failed nonoperative treatment. Surgical options include excision, acromioplasty, and open reduction and internal fixation. The purpose of this study is to summarize the described methods and compare their reported outcomes with the goal to provide direction on how to surgically manage os acromiale. We performed a systematic review of the current medical literature. Fifteen studies met all the inclusion criteria. Two hundred eleven total subjects (220 shoulders) underwent surgical treatment for a symptomatic os acromiale. There were 140 men and 71 women with a mean age of 49.6 ± 9.1 years. The mean follow-up duration was 40 ± 11.6 months. Surgical techniques used in the included studies were excision, acromioplasty, and open reduction with internal fixation. Concurrent surgical procedures performed were also included. Meso-os acromiale was the most common type (167 cases, 94.4%). The most common surgical technique was internal fixation (135 cases, 60.8%), with screw fixation being the majority (76 cases, 56.3%). Excision (65 cases, 29.3%) was the second most used technique. The most common concurrent surgical procedure performed was rotator cuff repair (125 cases, 56.3%), followed by distal clavicle excision (31 cases, 14%). All surgical techniques employed resulted in improvement in postsurgical clinical outcomes without any technique demonstrating superior results. Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes.

Superior capsule reconstruction for irreparable rotator cuff tears: a systematic review of biomechanical and clinical outcomes by graftxa0type

17-09-2019 – Justin L. Makovicka, Andrew S. Chung, Karan A. Patel, David G. Deckey, Jeffrey D. Hassebrock, John M. Tokish

Journal Article, Review

Superior capsular reconstruction (SCR) has recently been proposed as a surgical solution to the irreparable rotator cuff tear and has gained popularity because of promising early results. Therefore, the purpose of this study is to review the biomechanical and clinical outcomes in shoulders with this condition treated with SCR. A systematic review was conducted following PRISMA guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported biomechanical, radiographic, or clinical outcomes data after undergoing SCR in shoulders with irreparable rotator cuff tears. Studies were broken down into 3 categories: cadaveric biomechanical studies, autograft clinical outcome studies, and allograft clinical outcome studies. Biomechanical, radiographic, patient-reported, and functional outcomes data were recorded for each study. Eight cadaveric biomechanical studies, 5 autograft clinical studies, and 4 allograft clinical studies met inclusion criteria. In biomechanical studies, subacromial contact pressure and superior humeral translation were decreased in most tested scenarios. An increase in American Shoulder and Elbow Surgeons (ASES) scores, forward elevation and external rotation values, and acromiohumeral distance (AHD) were found in all autograft clinical studies reporting. Allograft clinical studies reported increases in ASES scores, forward elevation values, and AHD but decreases in visual analog scale scores in all studies reporting. SCR is emerging as a viable surgical option to address the irreparable rotator cuff tear. Biomechanical studies suggest that the humeral head-stabilizing effect of SCR appears to translate into improved clinical outcomes. Future research should focus on further defining the indications, limitations, and optimal technique.

A systematic review of patient-reported outcome measures used in shoulder instability research

10-09-2019 – Joseph H. Whittle, Susan E. Peters, Silvia Manzanero, Phillip F. Duke

Journal Article, Review

Shoulder instability is extremely common, with various outcome scores used to assess its progression after treatment. This review was performed to identify the scores most commonly used and to evaluate them according to the 4 core domains of shoulder trials (according to the Core Outcome Measures in Effectiveness Trials [COMET] initiative) and their respective psychometric qualities. A systematic review of the literature of 3 databases (MEDLINE, Embase, PubMed) was undertaken. Studies were identified using eligibility criteria and critically appraised by 2 authors. Data were extracted using an a priori template. Outcome scores were identified and assessed regarding COMET domain inclusion and their psychometric properties. The most frequently used scores were the Rowe (58%), Constant (33%), Western Ontario Shoulder Instability Index (WOSI; 24%), and American Shoulder and Elbow Surgeons (23%) scores. The majority of outcome scores assessed pain and all assessed physical functioning. Quality of life and a global assessment of treatment success were rarely incorporated. No single outcome score considered all core COMET domains. The WOSI was the most acceptable measure of those assessed with respect to its validity, reliability, and responsiveness. The WOSI incorporated 3 of the 4 core domains for shoulder trials (pain, physical functioning, and health-related quality of life). It had the most psychometric testing of the identified scores, confirming its reliability, validity, and responsiveness in the setting of shoulder instability. We recommend its use in this setting; however, it should be supplemented with additional outcome scores, such as the University of California-Los Angeles score, to cover all of the core COMET domains.

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

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

Journal Article

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

A comparison of deltopectoral versus Judet approach for glenoid exposure

31-08-2019 – Rongguang Ao, Zhen Jian, Jianhua Zhou, Xinhua Jiang, Baoqing Yu

Journal Article

Open reduction-internal fixation via an anterior or posterior approach is a widely used method for treating displaced glenoid fractures. This study aimed to identify the exposure range of the glenoid rim by these 2 approaches (deltopectoral and Judet approaches) and provide reference data for the choice of surgical approach. Twelve cadaveric shoulders were dissected. Both deltopectoral and Judet approaches were performed on each shoulder to mark the glenoid fracture. In addition, the shoulder was disarticulated to record the exposure range of the glenoid rim. For the deltopectoral approach, the range of the exposed glenoid rim was from 5:50 to 11:30, which accounted for about 47.2% of the clock face. For the Judet approach, the range of the exposed glenoid rim was from 1:30 to 6:20, which accounted for about 40.3% of the clock face. Along the inferior glenoid, there was an area of partial overlap for the 2 approaches. The superior glenoid rim located from 11:30 to 1:30 was considered inaccessible, as it could not be exposed by the 2 approaches. Less than 50% of the glenoid rim can be exposed by the deltopectoral or Judet approach. With a single approach, it may be difficult to expose and fix some complex glenoid fractures. The superior part of the glenoid fracture is the non-access area via the deltopectoral or Judet approach.

Single Assessment Numeric Evaluation (SANE) correlates with American Shoulder and Elbow Surgeons score and Western Ontario Rotator Cuff index in patients undergoing arthroscopic rotator cuff repair

23-09-2019 – John R. Wickman, Brian C. Lau, Melissa B. Scribani, Jocelyn R. Wittstein

Journal Article

Patient-reported outcomes continue to grow in importance. This study compared the Single Assessment Numeric Evaluation (SANE) score with the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff (WORC) index score in patients before and after primary rotator cuff repair. This study was a retrospective review of a prospectively filled database of 333 subjects who underwent primary rotator cuff repair by a single surgeon between 2010 and 2017. The database included preoperative and postoperative SANE, ASES, and WORC evaluations. The mean follow-up time was 37.5 months. Spearman correlation coefficients were calculated comparing each score preoperatively and at least 1 year postoperatively. A strong correlation was found between the SANE and ASES scores of subjects in the preoperative period (r = 0.769, P < .0001) and the follow-up period of at least 1 year (r = 0.781, P < .0001). A similarly strong correlation was found between the SANE and WORC scores of subjects in the preoperative period (r = 0.757, P < .0001) and the follow-up period of at least 1 year (r = 0.813, P < .0001). On stratification analysis, correlation of SANE scores with ASES and WORC scores was found when subjects were grouped by sex, age, cuff tear size, and workers' compensation status. This study shows a significant correlation between the SANE, ASES, and WORC scores of primary rotator cuff repair subjects in the preoperative and long-term follow-up periods. We recommend the SANE score as an adjunct to clinical outcome data that can be used in patients regardless of sex, cuff tear size, or workers' compensation status.

Adaptation and transcultural translation of the Rotator Cuff Quality of Life questionnaire into Spanish

30-09-2019 – Laura Rodríguez Rodríguez, Tomás Gallego Izquierdo, Daniel Pecos Martín

Journal Article

The objective of this study was the transcultural adaptation of the Rotator Cuff Quality of Life questionnaire and the determination of the reliability and validity of the questionnaire in the Spanish population with rotator cuff disease. One of the translators was a physiotherapist, and the other was an English philologist. The participants comprised 170 subjects with rotator cuff pathology. Test-retest reliability was established by the intraclass correlation coefficient. Internal consistency was established using the Cronbach α. Convergent validity was established by comparison with the Disabilities of the Arm, Shoulder and Hand questionnaire, Shoulder Pain and Disability Index, Spanish version of the Oxford Shoulder Score, and Spanish version of the Western Ontario Shoulder Instability index using the Spearman correlation coefficient. Estimation of the error in the measurements was calculated with the standard error of measurement. Assessment of reproducibility was performed with 30 minutes between the first and second administrations of the questionnaire. The Cronbach α was 0.99, showing high internal consistency. The intraclass correlation coefficient was 0.9 (95% confidence interval, 0.99-0.99; P < .001), indicating high test-retest reliability. The Spearman correlation coefficient showed a good relationship in all cases: Disabilities of the Arm, Shoulder and Hand, ρ = 0.9 (P < .001); Oxford Shoulder Score, ρ = 0.7 (P < .001); Shoulder Pain and Disability Index, ρ = 0.8 (P < .001); and Western Ontario Shoulder Instability index, ρ = 0.8 (P < .001). The standard error of measurement indicated little variability in the measurements (2.7%). The Spanish version of the Rotator Cuff Quality of Life questionnaire is a valid and reliable instrument for the subjective evaluation of patients with a diagnosis of rotator cuff pathology in the Spanish population.

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

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

Journal Article

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

Closed manipulation under anesthesia for pediatric post-traumatic elbow arthrofibrosis

19-01-2020 – Ajinkya A. Rane, Brittany N. Garcia, Angela A. Wang

Journal Article

Post-traumatic elbow arthrofibrosis (PEA) and its associated limitations to elbow range of motion (ROM) are a recognized consequence of trauma to the pediatric elbow. Closed manipulation under anesthesia (CMUA) of the elbow can be performed in pediatric patients as a nonoperative attempt to improve dysfunctional ROM. Minimal outcome data to support CMUA exist. The study evaluates the efficacy of CMUA for PEA in pediatric patients. Patients younger than 18 years who underwent CMUA (Current Procedural Terminology code 24300) for PEA between 2005 and 2015 at 3 institutions were included. A retrospective chart review was performed to collect demographic data and ROM premanipulation and at last follow-up. Paired 2-tailed t tests were used to compare pre- and postmanipulation elbow ROM. Thirteen patients with a mean age of 12.2 ± 2.6 years (range 6.7-15.6 years) met the inclusion criteria. Median time to CMUA from initial surgery was 4.2 months (interquartile range [IQR] 3.6-8.4, range 1.4-19.7 months). Median follow-up time was 6 months with an IQR of 3.3-10.0 months. At last follow-up, there was significant improvement in elbow flexion of 22° ± 17° (P < .001) and extension of 29° ± 21° (P < .001). The average premanipulation motion arc of 60° ± 24° significantly increased to 110° ± 22° at final assessment (P < .001). CMUA appears to be a valuable alternative and reliable procedure for improving PEA in pediatric patients who exhaust nonoperative interventions.

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

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

Journal Article

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

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions

18-12-2019 – Dennis A. DeBernardis, John G. Horneff, Daniel E. Davis, Matthew L. Ramsey, Manuel C. Pontes, Luke S. Austin

Journal Article

The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery. We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts. A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group. Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.

Predictors of elbow torque among professional baseball pitchers

10-12-2019 – Vincent A. Lizzio, Caleb M. Gulledge, D. Grace Smith, Jason E. Meldau, Peter A. Borowsky, Vasilios Moutzouros, Eric C. Makhni

Journal Article

Overuse injuries of the shoulder and elbow continue to be prevalent in elite baseball pitchers. Pitch velocity has been shown to impact medial elbow torque in adolescent baseball pitchers. However, the determinants of medial elbow torque in professional baseball pitchers are not known. To determine the influence of pitch type, velocity, and player characteristics on medial elbow torque in professional baseball pitchers. Professional baseball pitchers were recruited for participation. Height, weight, body mass index (BMI), and throwing arm measurements were obtained for all study participants. While wearing a gyroscopic sensor equipped with an accelerometer, participants were instructed to throw a standard, randomized sequence of fastballs, changeups, and curveballs. Elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity were recorded for each pitch. A linear mixed model was used to evaluate the association of pitch type with each pitch parameter, adjusting for pitchers’ demographics. A total of 12 professional baseball pitchers were included in this study. Among the pitch types, medial elbow torque was significantly higher in fastballs than in curveballs (P = .001). An increased BMI value was independently associated with decreased elbow torque in pitchers (P = .035). Fastballs place significantly higher torque on the medial elbow than do curveballs, which is consistent with previous studies done on high school and collegiate populations. Pitchers with a higher BMI experience significantly less torque across the medial elbow.

The arthroscopic triple-row modified suture bridge technique for rotator cuff repair: functional outcome and repair integrity

28-08-2019 – Johannes Buckup, Daniel Smolen, Florian Hess, Christoph Sternberg, Jan Leuzinger

Journal Article

The optimal technique for arthroscopic rotator cuff repair is still controversial. Large tears with a high grade of retraction have an especially high risk of retearing. This study reports the clinical and radiologic results of a triple-row modified suture bridge technique for the treatment of full-thickness rotator cuff tears with medium and high grades of retraction. A total of 101 shoulders in 100 patients underwent a triple-row modified suture bridge reconstruction for full-thickness rotator cuff tears with retraction grade II and grade III according to Patte; 81 patients were reached for follow-up 36.2 months after surgery. At follow-up, clinical outcome was assessed by the American Shoulder and Elbow Surgeons score, subjective shoulder value, visual analog scale score, University of California-Los Angeles shoulder score, and Constant score (CS). At follow-up, an ultrasound examination was performed to determine tendon integrity or retears in all patients. The overall retear rate was 4.9% (4/81). The clinical outcome was good to excellent (American Shoulder and Elbow Surgeons score, 94 ± 11; subjective shoulder value, 92 ± 12; University of California-Los Angeles shoulder score, 33 ± 5; Constant score, 90 ± 9). In the radiologic follow-up, no retear was found in any of the follow-up patients after an average of 36.2 months. There was no significant difference in clinical outcome parameters between rotator cuff tears Patte II and Patte III (P > .05). For tears with a high grade of retraction, surgical treatment using a triple-row modified suture bridge technique represents a good treatment option with a low rate of retearing and good to excellent clinical results.

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.