Arthroscopic Repair of Combined Bankart and SLAP Lesions: Operative Techniques and Clinical Results

Background

To evaluate the clinical results and operation technique of arthroscopic repair of combined Bankart and superior labrum anterior to posterior (SLAP) lesions, all of which had an anterior-inferior Bankart lesion that continued superiorly to include separation of the biceps anchor in the patients presenting recurrent shoulder dislocations.

Methods

From May 2003 to January 2006, we reviewed 15 cases with combined Bankart and SLAP lesions among 62 patients with recurrent shoulder dislocations who underwent arthroscopic repair. The average age at surgery was 24.2 years (range, 16 to 38 years), with an average follow-up period of 15 months (range, 13 to 28 months). During the operation, we repaired the unstable SLAP lesion first with absorbable suture anchors and then also repaired Bankart lesion from the inferior to superior fashion. We analyzed the preoperative and postoperative results by visual analogue scale (VAS) for pain, the range of motion, American Shoulder and Elbow Surgeon (ASES) and Rowe shoulder scoring systems. We compared the results with the isolated Bankart lesion.

Results

VAS for pain was decreased from preoperative 4.9 to postoperative 1.9. Mean ASES and Rowe shoulder scores were improved from preoperative 56.4 and 33.7 to postoperative 91.8 and 94.1, respectively. There were no specific complication and no significant limitation of motion more than 10 degree at final follow-up. We found the range of motions after the arthroscopic repair in combined lesions were gained more slowly than in patients with isolated Bankart lesions.

Conclusions

In recurrent dislocation of the shoulder with combined Bankart and SLAP lesion, arthroscopic repair using absorbable suture anchors produced favorable clinical results. Although it has technical difficulty, the concomitant unstable SLAP lesion should be repaired in a manner that stabilizes the glenohumeral joint, as the Bankart lesion can be repaired if the unstable SLAP lesion is repaired first.     

Recurrent anterior shoulder instability in patients 40–60 years old. Accompanying injuries and patient outcomes of arthroscopic repair

BackgroundAccompanying injuries are frequently seen in middle aged patients with recurrent instability. The aim of this study was to elucidate the associated injuries, report patient outcomes of the following arthroscopic instability surgery regarding 40–60 years old patients with recurrent shoulder instability.MethodsPatients that underwent arthroscopic instability surgery due to recurrent shoulder instability between February 2008 and November 2015, and which were 40–60 years old were included and evaluated retrospectively. Minimum follow-up duration was 24 months. Anterior-inferior labral injuries and accompanying pathologies such as rotator cuff tears and SLAP lesions were documented. Postoperative patient-reported outcome evaluation was made using Oxford Shoulder Instability Score.ResultsAmong 355 patients that underwent arthroscopic instability surgery, 88 patients which had pathology of recurrent instability were in the range of 40–60 years old. Patients who had previous shoulder surgery or fracture (n = 8) epileptic seizure history (n = 3), neurologic deficit (n = 2) were excluded from the study. 75 patients were included with a mean follow-up 69 ± 23 months (32–125). The percentage of middle-aged and elderly (40–60 years old) was 24.8% among recurrent shoulder instability patients. 44% had isolated Bankart lesion whereas 56% revealed multiple pathologies. Bankart + SLAP lesions were found in 32%, whereas Bankart + Rotator Cuff tears in 26.7% (13 isolated supraspinatus, 4 supraspinatus + subscapularis, 1 isolated subscapularis full-thickness and 2 partial-thickness supraspinatus tears). The mean Oxford Shoulder Instability Score was 38.4 ± 5.2 (26–48). The scores of patients which were treated with labrum and rotator cuff repair (median 42, range 30–48) were significantly better than the patients who were treated with isolated labrum repair (median 39, range 20–46) (p = 0.015). There was no difference regarding patients with or without SLAP repair (median 39 vs 39 and range 30–48 vs 20–48, respectively) (p = 0.702).ConclusionsArthroscopic repair of capsulolabral lesions is a safe and successful technique in 40–60 years old patients. Furthermore, the presence of repaired rotator cuff tears led to even superior results. Accompanying SLAP lesions did not affect the results.Study designRetrospective Case Series.Level of evidence4, Retrospective Case Series.     

Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results

Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.     

Arthroscopic stabilization of type II SLAP lesions using an absorbable tack

Purpose: To document the outcomes of arthroscopic stabilization of Snyder type II SLAP (superior labrum, anterior and posterior) lesions, using a bioabsorbable tack. Type of Study: A case series. Methods: Twenty-five SLAP lesions were repaired arthroscopically using a bioabsorbable tack. There were 22 recreational, 2 high school, and 1 professional athlete in this group. Shoulder function was surveyed at a mean follow-up of 35 months (range, 24 to 51 months) using the UCLA and ASES shoulder scoring algorithms. Results: Shoulder function improved in 24 of the 25 cases. Follow-up UCLA scores averaged 32 points with 9 patients scoring as excellent, 13 good, 2 fair, and 1 poor, for an overall success rate of 88%. ASES shoulder scores similarly improved from a preoperative average of 45 points to a postoperative average of 92. All but 2 of the athletes had returned to their preinjury level of sports participation. Conclusions: Detachment of the superior labrum from the glenoid is recognized as a problematic injury in throwing athletes and others who engage in repetitive overhead activities. We conclude from our experience that using an absorbable tack to repair type II SLAP lesions is an effective treatment, even in athletes with high demands and expectations for shoulder function.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 19–24     

Inlay hemiarthroplasty of the humeral head for nontraumatic osteonecrosis

BackgroundOsteonecrosis of the humeral head often occurs in younger individuals and presents a difficult clinical situation. The purpose of this study was to evaluate the patient reported outcomes in patients undergoing inlay hemiarthroplasty for nontraumatic osteonecrosis of the humeral head. We hypothesized that patients would achieve a meaningful clinical improvement.MethodsA retrospective review of prospectively collected data on 9 patients undergoing inlay hemiarthroplasty for humeral head osteonecrosis was conducted. The American Shoulder and Elbow Surgeons Shoulder score (ASES), Simple Shoulder Test (SST), visual analog scale for pain (VAS), and range of motion measurements were collected preoperatively and at final follow-up. Radiographs were evaluated for any evidence of component loosening or glenoid wear. The primary outcome was achievement of substantial clinical benefit (SCB) for ASES.ResultsPostoperatively at a mean of 7.2 years the ASES improved from 35 to 73 (p = 0.011), the SST improved from 2 to 6 (p = 0.038), and the VAS for pain decreased from 7 to 3 (p = 0.009). Forward elevation increased from 96° to 138° (p = 0.012) and external rotation increased from 13° to 63° (p = 0.007). SCB for ASES was seen in 7 out of the 9 patients (78%). Asymptomatic mild or moderate glenoid wear was seen in 4/9 (44%) of patients. One patient (11%) developed symptomatic glenoid wear necessitating conversion to total shoulder arthroplasty.ConclusionInlay hemiarthroplasty offers a viable solution to osteonecrosis of the humeral head.Level of Evidence: Level IV; Treatment Study     

Predictors of patient satisfaction and outcomes following reverse total shoulder arthroplasty

BackgroundObjective clinical outcomes and patient satisfaction via patient reported outcome measures (PROMs) can vary following reverse total shoulder arthroplasty (rTSA). The purpose of this study was to analyze patient specific preoperative factors that may predict postoperative PROMs and satisfaction following rTSA.MethodProspective data was collected on 144 consecutive patients who underwent primary rTSA at our institution between 2012 and 2018, all with minimum 2 year follow-up. Age, gender, race, BMI, previous surgery on the index shoulder, and comorbidity burden were analyzed as potential predictors. Shoulder specific clinical measures were collected both pre- and postoperatively via range of motion testing with active abduction, internal, and external rotation. PROMs included global shoulder function, Simple Shoulder Test (SST) and the American Shoulder and Elbow Surgeons (ASES) scoring systems, and cumulative patient satisfaction. Statistical analysis included comparison of pre- and postoperative outcome measures across the cohort as a whole and between each of the potential predictors in question. The relationship between predictors and postoperative cumulative satisfaction was investigated, with specific attention to identify the strongest predictors and account for confounding variables. Statistical significance was determined at P < .05.ResultsAll range of motion scores and PROMs were significantly improved from preoperative to postoperative assessment. Patient satisfaction was excellent with 92% rating their shoulder as “much better” or “better.” Women and minority patients displayed significantly worse preoperative active abduction, SST, and ASES, but were found to have no significant difference in these measures postoperatively. Younger age was associated with a significantly worse postoperative ASES score. Female sex was associated with significantly higher postoperative satisfaction, while minority status was associated with significantly lower cumulative satisfaction. Postoperative global shoulder function, SST, and ASES were not significantly influenced by sex, race, previous surgery, BMI, or comorbidity burden. Postoperative ASES and global shoulder function demonstrated to be independent predictors of “much better” satisfaction rating.ConclusionPostoperative PROMs and cumulative satisfaction are not influenced by BMI, previous surgery, or comorbidity burden in our cohort. Relative to their respective counterparts, older patients, females, and white patients are more likely to demonstrate higher satisfaction with their outcome following rTSA as measured by PROMs or cumulative satisfaction. Improvements in the ASES and global shoulder function scores most consistently predict higher postoperative satisfaction.Level of evidenceLevel IV; Case Series; Treatment Study     

Open reduction internal fixation vs. reverse shoulder arthroplasty for the treatment of acute displaced proximal humerus fractures

BackgroundProximal humerus fractures are a frequent fragility fracture in the aging population and represent a challenge to the orthopedic surgeon. Open reduction internal fixation (ORIF) of these fractures is viable but technically challenging and associated with a high complication rate. Recently, reverse shoulder arthroplasty (RTSA) with tuberosity repair has become a popular and successful option for treating these fractures. The purpose of this study is to compare outcomes of ORIF and RTSA for treatment of proximal humerus fractures.MethodsAn age-matched group of 50 patients treated with ORIF (25) and RTSA (25) were assessed at an average follow-up of 4.4 years. American Shoulder and Elbow Surgeons score (ASES) and Simple Shoulder Test (SST), radiographs, range of motion, and complications were evaluated between the two groups.ResultsThe reoperation rate and major complications were higher in the ORIF group compared to RTSA. No major complications were observed in the RTSA group. Forward flexion in the RTSA patients (143.2 ± 23.1) was shown to be significantly greater than ORIF patients (121.4 ± 35.1) (p= 0.0125) but no significant differences were observed for shoulder external rotation or internal rotation. There was no difference in ASES and SST scores between groups.ConclusionThe current study demonstrates good clinical outcomes for both RTSA and ORIF. However, reoperation rate was higher with ORIF with locked plating compared to RTSA for fracture with tuberosity repair in an age matched population. RTSA may be a better treatment option than ORIF for 3- and 4-part fractures in patients older than 65.Level of evidenceLevel III     

Outcomes of nonoperative management of acromial stress fractures after reverse shoulder arthroplasty

IntroductionAcromial stress fractures (ASF) and stress reactions (ASR) are common complications after reverse shoulder arthroplasty (RSA), and have been shown to compromise outcomes. The purpose of this study was to determine the functional outcomes of patients with ASF and ASR treated nonoperatively.MethodsA total of 958 patients that underwent RSA were retrospectively reviewed. 43 (4.5%) were found to have ASF and 56 (5.7%) were found to have ASR. ASF were defined by tenderness over the acromion with identified fracture on radiographic imaging, and ASR was defined as tenderness without radiographic evidence of fracture. Functional outcomes were assessed via American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST) and VAS (Visual Analog scale) pain at a minimum of 2 years after RSA and one year from diagnosis of acromial pathology. The ASF patients were matched 3:1 to RSA controls without acromial pathology based on age, sex, indication, and implant.ResultsTwenty seven ASF and 35 ASR patients met inclusion criteria with a mean follow-up of 50.3 months after surgery (range: 24-108 months). Symptom onset after RSA occurred at 8.1 ± 8.9 months (range: 0.8-49.8) in ASFs and 7.5 ± 6.8 months (range: 1.0-41.3) in ASRs (P = .700). The ASF group included 20 (74%) females with an average age of 71.8 years, and the ASR group included 30 (86%) females with an average age of 72.9 years. ASF patients had inferior outcomes compared to controls in ASES (57.8 vs. 76.0, P = .001), SANE (59.1 vs. 78.8, P = .001), SST (5.1 vs. 7.5, P = .001), and VAS (3.3 vs. 1.2, P = .002). Additionally, ASF patients had significantly worse scores compared to ASR patients by VAS Pain (3.3 vs 1.7, P = .020), ASES (57.8 vs. 76.7, P = .001), SANE (59.1 vs. 81.1, P = .001), and SST (5.1 vs. 7.5, P = .001). Patients with ASR had comparable pain and function to controls in ASES (P = .858), SANE (P = .508), SST (P = .956), and VAS (P = .264) scores. Twenty-one (77.7%) ASF patients experienced fracture displacement and 13 (48.1%) went on to nonunion.ConclusionEarly follow-up of patients treated nonsurgically for ASF after RSA demonstrated worse pain and function compared to controls. The majority demonstrated further displacement after diagnosis and almost half developed a nonunion. Patients with ASR experienced temporary dysfunction with little impact on final outcome. Strategies to prevent and treat ASFs remain an area in need of innovation.Level of evidenceLevel IV; Case series     

Arthroscopic Modified Double‐Row Biceps Tenodesis versus Labral Repair for the Treatment of Isolated Type II SLAP Lesions in Non‐Overhead Athletes

ObjectiveTo evaluate the postoperative efficacy and the clinical outcomes of arthroscopic modified double‐row biceps tenodesis versus labral repair.MethodsA retrospective study was conducted in 56 patients with isolated type II superior labrum anterior and posterior (SLAP) lesions from March 2015 to November 2018. Thirty patients (male:female = 17:13) were treated with labral repair, and 26 patients (male:female = 15:11) were treated with modified double‐row biceps tenodesis. The average age of the labral repair group and the modified double‐row biceps tenodesis group were 42.8 ± 10.6 and 40.9 ± 10.2 years, respectively. Pre‐ and postoperative assessments with the visual analog scale (VAS), University of California Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores were compared between the two treatment groups. Additional outcome measures included patient satisfaction, the time to return to previous activities, workers'' compensation status, and postoperative complications.ResultsAt a 2‐year follow‐up, the tenodesis group showed significant differences in postoperative VAS (1.5 to 1.8, respectively; p = 0.008), patient satisfaction (92.3% vs. 46.7%, p < 0.001), and recovery time to return to their previous activities (6.8 ± 1.8 vs. 8.1 ± 1.5, p = 0.007) compared to the labral repair group; however, there was no significant difference in postoperative ASES and UCLA scores between the two groups. Additionally, one patient in the tenodesis group developed persistent postoperative stiffness, which was resolved by conservative treatment. In the labral repair group, two patients presented with persistent postoperative night pain, three developed persistent postoperative stiffness, and two required a subsequent capsular release.ConclusionsCompared with the labral repair group, the arthroscopic modified double‐row biceps tenodesis showed more encouraging postoperative pain reduction, earlier recovery to previous activities, and higher patient satisfaction.     

Outcomes for reverse total shoulder arthroplasty after failed open reduction internal fixation versus primary reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundThe purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF.MethodsWe performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts.ResultsIn total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0 ± 13.5) than for delayed RTSA (64.0 ± 27.2, P = 0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P = 0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P = 0.035). No difference was detected between groups in postoperative external rotation (P = 0.152) or internal rotation (P = 0.872). Radiographically, the tuberosities healed in an anatomic position in 70% of the primary cases versus the prior ORIF group in which the tuberosities were in an anatomic position in all cases (P = 0.007).ConclusionsIn an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study.Level of EvidenceLevel III; Retrospective Comparative Study     

The impact of subscapularis integrity on functional outcome in reverse total shoulder arthroplasty utilizing a 135˚ stem

BackgroundReverse shoulder arthroplasty (RSA) predictably restores overhead function and provides pain relief in patients with glenohumeral arthritis and rotator cuff deficiency. Implant design with an anatomic inclination angle of 135˚ may provide an advantage in the healing rates of subscapularis tendon (SST) repairs. The purpose of this study was to use ultrasound to evaluate the subscapularis repair healing rate, and secondarily, to compare outcomes between healed and non-healed SSTs, in patients undergoing RSA with a 135˚ inclination angle.MethodsA prospectively collected, multicenter shoulder arthroplasty registry was queried to identify patients undergoing RSA with a 135˚ inclination stem with a minimum of 1 year follow-up. Ultrasound analysis was performed at final follow-up to assess subscapularis integrity. Exclusion criteria included RSA for fracture, fracture sequelae or failed prior arthroplasty. Outcome measures included American Shoulder and Elbow Surgeons score (ASES), Western Ontario Osteoarthritis of the Shoulder (WOOS), Single Anatomic Numeric Evaluation (SANE), and Constant scores. Additionally, subscapularis functional assessments included range of motion, belly-press and shirt-tuck tests. Statistical analysis was performed using ANOVA, Chi-square, and student t-tests with SPSS. Results were considered significant at P < .05.ResultsSeventy-eight patients meeting the inclusion criteria were identified from the registry, however, only seventy-five patients had ultrasound and healing data. The subscapularis was repaired in 60 patients and healing via ultrasound was noted in 56.7% (34/60). In most cases, a subscapularis peel was performed, with lesser tuberosity osteotomy performed in 9.38% of cases. Patients whose subscapularis was repaired were found to be older (72.2 vs. 64.9, P < .001) and the majority of patients with an unrepaired subscapularis were male (13/15, 86.7% unrepaired vs. 27/60, 45.0% repaired). Both healed and non-healed patient cohorts showed statistical improvement in all pain and functional outcome scores from their baselines. However, there were no significant differences in outcome scores between healed and non-healed SST. With regards to SST repair, only overall WOOS (Δ+15.62, P = .049) and physical component of the WOOS score (Δ+15.97, P = .040) were higher in patients with nonrepaired SST. There was no correlation between the ability to perform a belly-press or shirt-tuck test and subscapularis repair or evidence of radiographic healing. Patients who did not have their subscapularis repaired demonstrated greater passive external rotation at the side from 31° to 51° (P = .044). A significant increase in passive forward flexion was noted in patients with healed subscapularis from 117° to 135° (P = .042). There was no statistical difference in active range of motion between either the repaired/nonrepaired or healed/non-healed cohorts.ConclusionOur study demonstrates a healing rate of 57% following repair in patients undergoing RSA with a 135˚ angle. Standardized outcome measures overall demonstrated no difference between patients with a healed subscapularis compared to those with a non-healed or unrepaired subscapularis.Level of EvidenceIV, case series, treatment study.     

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair

Purpose:Arthroscopic transosseous (TO) rotator cuff repair has recently emerged as a new option for surgical treatment of symptomatic rotator cuff tears. Limited data is available regarding outcomes using this technique. This study evaluated midterm clinical outcomes following a novel arthroscopic TO (anchorless) rotator cuff repair technique.Results:Statistically significant improvements were noted in forward flexion, external rotation and internal rotation (P < 0.0001). Average postoperative subjective shoulder value was 93.7, simple shoulder test 11.6, and American Shoulder and Elbow Surgeons (ASES) score 94.6. According to ASES scores, results for the 109 shoulders available for final follow-up were excellent in 95 (87.1%), good in 8 (7.3%), fair in 3 (2.8%), and poor in 3 (2.8%). There was no difference in ROM or outcome scores in patients who underwent a concomitant biceps procedure (tenodesis or tenotomy) compared with those who did not. Furthermore, there was no significant difference in outcome between patients who underwent either biceps tenodesis or tenotomy. Age, history of injury preceding the onset of pain, tear size, number of TO tunnels required to perform the repair, and presence of fatty infiltration did not correlate with postoperative ROM or subjective outcome measures at final follow-up. Two complications and four failures were noted.Conclusions:Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.

Level of Evidence:

Level IV     

Prevalence and Clinical Impact of Acromial Cupping after Arthroscopic Rotator Cuff Repair: Does Acromioplasty Matter?

BackgroundAlthough the effectiveness of acromioplasty is controversial, it is commonly performed during rotator cuff repair to reduce external impingement. During follow-up, osteolysis under the acromion (acromial cupping) could be observed. However, this phenomenon has been rarely addressed in the literature. The purpose of this study was to compare the prevalence and severity of acromial cupping after rotator cuff repair depending on the concomitant performance of acromioplasty and evaluate the influence of acromial cupping on clinical and radiological outcome.MethodsThis is a retrospective study involving patients who underwent arthroscopic rotator cuff repair for small-to-large full-thickness rotator cuff tears from October 2015 to March 2019 and clinical follow-up and magnetic resonance imaging at least 1 year postoperatively. A total of 110 patients were enrolled and divided into two groups depending on whether acromioplasty had been performed (group A) or not (group N). The prevalence of acromial cupping was evaluated in each group. In addition, we stratified patients according to the severity of acromial cupping to investigate its influence on healing and functional scores (visual analog scale [VAS], American Shoulder and Elbow Surgeons [ASES] score, simple shoulder test [SST], and Constant-Murley score).ResultsThere were 85 patients in group A and 25 patients in group N. The prevalence of acromial cupping and acromial cysts was as follows: 36.4% (40 patients) and 6.4% (7 patients), respectively, in the total subjects; 43.5% (37/85) and 5.9% (5/85), respectively, in group A; and 12.0% (3/25) and 8.0% (2/25), respectively, in group N. The prevalence of acromial cupping was significantly different between the two groups (p = 0.012). However, functional outcomes were not significantly different between groups stratified by the severity of acromial cupping (VAS, p = 0.464; ASES score, p = 0.902; SST, p = 0.816; and Constant-Murley score, p = 0.117). The difference in healing rate was statistically insignificant between groups (p = 0.726).ConclusionsThe incidence and severity of acromial cupping were significantly greater in patients who underwent rotator cuff repair with acromioplasty. It was a relatively common phenomenon, especially after acromioplasty. However, neither the existence nor the severity of acromial cupping affected functional outcomes or healing.     

Which Risk Factors Are Associated with Pain and Patient-reported Function in Patients with a Rotator Cuff Tear?

BackgroundPatient-reported measures guide physicians in clinical decision making and therefore it is critical to determine what clinical factors are associated with these scores. Psychological and physical factors are commonly studied separately in patients with rotator cuff tears to determine their influence on outcomes. It is well established that psychological distress and scapular motion change in the presence of a symptomatic rotator cuff tear. However, these factors have not been studied simultaneously in a clinical setting to determine their association with shoulder outcome scores.Question/purposeAfter controlling for relevant confounding variables, what physical and psychological factors are associated with better (1) American Shoulder and Elbow Surgeons (ASES) scores for function, (2) ASES pain scores, and (3) total ASES scores?MethodsFifty-nine patients with a potential symptomatic rotator cuff tear were recruited and agreed to participate in this cross-sectional study. Of those, 85% (50 of 59) met eligibility criteria for a primary diagnosis of an MRI-confirmed symptomatic partial-thickness or full-thickness rotator cuff tear without a history of shoulder surgery. Demographics, rotator cuff tear size, arm flexion, and clinical scapular motion during active arm flexion were evaluated by experienced examiners using standardized procedures. Patients completed the ASES questionnaire and the Optimal Screening for Prediction of Referral and Outcomes-Yellow Flag assessment form, which measures 11 different pain-related psychological distress symptoms. Three separate stepwise multiple linear regression analyses were performed for ASES pain, function, and total scores, with significance set at p < 0.05.ResultsThis model found that ASES function scores were associated with four factors: older age, increased arm flexion, increased percentage of scapular external rotation during arm flexion, and increased scores for acceptance of chronic pain (adjusted r² = 0.67; p = 0.01). Those four factors appear to explain 67% of the observed variance in ASES function scores in patients with rotator cuff tears. Furthermore, increased percentage of scapular external rotation during arm flexion and decreased fear-avoidance beliefs related to physical activity scores (adjusted r² = 0.36; p < 0.01) were associated with better ASES pain scores. And finally, better ASES total scores were associated with four factors: increased arm flexion, increased percentage of scapular upward rotation, increased scapular external rotation during arm flexion, and decreased fear-avoidance beliefs related to physical activity scores (adjusted r² = 0.65; p < 0.001).ConclusionOur results favor adopting a comprehensive biopsychological clinical assessment for patients with rotator cuff tears that specifically includes humeral and scapular motion, fear-avoidance behaviors, and pain coping behaviors along with demographics. These particular physical and psychological variables were found to be associated with the ASES and, therefore, should be clinically examined simultaneously and targeted as part of a tailored treatment plan.Level of EvidenceLevel II, prognostic study.     

Correlation of patient-reported outcome measurement information system-upper extremity with American Shoulder and Elbow Surgeons scores in shoulder arthroplasty

BackgroundMultiple outcome measure surveys are available to assess preoperative and postoperative outcomes for a variety of orthopedic procedures such as shoulder arthroplasty. Although legacy instruments such as American Shoulder and Elbow Surgeons (ASES) remain popular, there remains no singular gold standard survey instrument for shoulder arthroplasty patients, and alternative instruments have been developed to better capture clinical outcomes. The goal of this study is to compare the efficacy of Patient-Reported Outcome Measurement Information System-Upper Extremity (PROMIS-UE) using computer adaptive technology with ASES scores both preoperatively and postoperatively in shoulder arthroplasty patients. Our hypothesis is that there would be a strong correlation between PROMIS-UE and ASES scores both preoperatively and postoperatively in total shoulder arthroplasty patients.MethodsPatients who underwent total shoulder arthroplasty and agreed to complete baseline and 1-year follow-up of ASES and PROMIS-UE scores were included. Patients also completed PROMIS-Physical Function (PROMIS-PF) as a third point comparison. Responses to these instruments were statistically analyzed and compared using Pearson correlation coefficients. Floor and ceiling effects were then calculated.ResultsNinety patients were included in this study, all of whom completed the PROMIS-UE, PROMIS-PF, and ASES surveys both preoperatively and 12 months postoperatively. The mean age in this cohort was 68.9 years (standard deviation [SD] 8.4 years, range 39-89). The mean preoperative and postoperative PROMIS-UE scores were 26.6 (SD 6.7, range 14.7-44.6) and 41.8 (SD 10.3, range 20.2-56.4) respectively. Mean preoperative and postoperative PROMIS-PF computer adaptive technology scores were 35.7 (SD 9.54, range 34.2-64) and 44.3 (SD 9.22, range 23.5-73.3) respectively. The mean ASES score was 37.5 preoperatively (SD 18.0, range 5-99.5) and 77.5 postoperatively (SD 20.5, range 25.0-100.0). PROMIS-UE demonstrated a moderate correlation with ASES preoperatively and a strong correlation postoperatively (r = 0.52, confidence interval 0.27-0.60; r = 0.70, confidence interval 0.55-0.78, respectively). PROMIS-UE demonstrated a minor floor effect preoperatively (7.8%) but significant ceiling effect postoperatively (24.4%) and ASES demonstrated a mild ceiling effect at final follow-up (8.9%). There were otherwise no other floor or ceiling effects at all other time points across each survey.ConclusionPROMIS-UE correlates well with ASES at both baseline and 1-year postoperation for patients undergoing total shoulder replacement. In addition, the change seen between both baseline and 1 year outcome scores for both scoring systems also correlates strongly, suggesting that PROMIS-UE may be a suitable alternative to ASES for this patient population.     

Comparison of Arthroscopic Debridement and Repair in the Treatment of Ellman Grade II Bursal‐side Partial‐thickness Rotator Cuff Tears: A Prospective Randomized Controlled Trial

ObjectiveTo compare the effects of arthroscopic debridement and repair in treating Ellman grade II bursal‐side partial‐thickness rotator cuff tears.MethodsThis is a single‐center, prospective, randomized controlled trial. From September 2017 to April 2019, 78 patients underwent arthroscopic debridement (35 patients) or repair (43 patients) due to Ellman grade II bursal‐side partial‐thickness rotator cuff tears. Twenty‐six men and 52 women were included in the study, with an average age of 56.31 years (range, 42 to 74 years). After the acromioplasty was formed, the debridement group only performed stump refreshing and surrounding soft tissue cleaning, while the repair group converted the partial tears into full‐thickness tears and then sutured them by single row or suture bridge technique. The visual analogue scale (VAS), Constant‐Murley shoulder (CMS), American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) scores were used to evaluate clinical results preoperatively and at 6, 12, and 18 months postoperatively. Magnetic resonance imaging was used to assess the integrity of the rotator cuff, muscle atrophy, and fat infiltration.ResultsA total of 85 patients met the inclusion criteria and were randomly divided into the debridement group (41 patients) and the repair group (43 patients). During the 18‐month follow‐up period, a total of seven patients were lost to follow‐up. The functional scores of both groups were significantly improved: the VAS score decreased 5.06 and 4.63 in the debridement group (5.77 preoperative to 0.71 postoperative) and the repair group (5.49 to 0.86) (P < 0.05). Moreover, the CMS, ASES, UCLA scores increased 51.63, 58.24, 20.57 in debridement group (39.46 to 91.09, 34.14 to 92.38, 13.29 to 33.86), and increased 48.14, 60.53, 20.93 in repair group (43.63 to 91.77, 33.10 to 93.63, 12.58 to 33.51) (P < 0.05). No significant differences were found in functional scores between the two groups at 6, 12, and 18 months postoperatively (P > 0.05). The magnetic resonance imaging showed no re‐tears, and no difference was observed in the degree of muscle atrophy and fat infiltration between the two groups (P > 0.05). Except for four cases of shoulder stiffness, no other obvious surgery‐related complications were found.ConclusionFor Ellman grade II bursal‐side partial‐thickness rotator cuff tears, both the debridement and repair groups achieved good results during 18‐month follow‐ups, with no difference between the two groups.     

Clinical outcomes of revision biceps tenodesis

Purpose:

Biceps tenotomy and tenodesis are effective treatment options for biceps pathology, but outcomes of revision surgery are not known. This study examines the clinical outcomes of patients who have undergone a revision biceps tenodesis.

Materials and Methods:

A retrospective review of all patients since 2004 (N = 21) who had undergone a revision biceps tenodesis with greater than 6-month follow-up was completed. A follow-up survey was carried out, and the visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and University of California – Los Angeles (UCLA) scores were obtained, along with SF-12 Mental (MCS-12) and Physical Component Summaries (PCS-12).

Results:

Indications for revision surgery were continued pain (14) and ruptured biceps (7). Complete follow-up examinations were performed in 15 of 21 patients (71.4%). Average follow-up was 33.4 ± 23.5 months. The mean postoperative scores were 1.9 out of 10, VAS; 79 out of 100, SANE; 10.2 out of 12, SST; 83 out of 100, ASES; 29 out of 35, UCLA; 44, PCS- 12; and 47.1, MCS- 12. Five patients were considered failures with a UCLA score below 27. Seventeen of twenty-one patient underwent concomitant procedures. Complete preoperative and postoperative data were collected for 14 patients. All scores demonstrated highly significant improvement from preoperative levels (P < 0.005), except for the MCS-12. There was no statistically significant difference in the outcomes of revision due to rupture and revision due to persistent pain.

Conclusions:

The results suggest that revision subpectoral biceps tenodesis provides significant pain relief and improvement in functional outcomes at a mean follow-up of 33.4 months.

Level of Evidence:

Case Series, Level 4.     

Does diabetes affect functional outcomes after shoulder arthroplasty?

ObjectivesThe purpose of this study was to assess whether diabetes affects functional and physical outcomes following shoulder arthroplastyMethodsA cohort of 140 patients were tested preoperatively, at an early follow-up visit (between 3-6 months) and at late follow-up visit (between 1-3 years) following shoulder arthroplasty. The American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form measured shoulder pain and function and the Short-Form-12 (SF-12) measured physical health status. Shoulder goniometry and dynamometry were used to assess motion and strength. Diabetic status was self-reported.ResultsThere were significant improvements in function and physical health status for both diabetic and nondiabetic patients at the late follow-up visit. For patients with diabetes, shoulder function (ASES: 0-30) improved from 5 (5) to 18 (6) scores (p < 0.001) and physical health status improved from 27 (6) to 38 (8) scores (p < 0.001). For patients without diabetes, shoulder function improved from 8 (5) to 19 (8) scores (p < 0.001) and physical health status improved from 31 (8) to 40 (12) scores (p < 0.001). No significant differences between diabetic and nondiabetic patients was detected at the late follow-up.ConclusionPatients with diabetes achieve large clinical benefits from shoulder arthroplasty, with follow-up outcomes equally positive to those without diabetes. Future prospective studies with a larger sample size of patients with diabetes are needed to confirm the results of this study.Level of evidenceII     

Midterm results of two-stage revision surgery for periprosthetic shoulder infection

BackgroundTo our knowledge, no studies have reported clinical results at a midterm follow-up after two-stage revision for periprosthetic shoulder infection (PSI). Our purpose was to determine the recurrent infection rate and clinical outcomes of two-stage revision for PSI at a minimum follow-up of 5 years. The secondary aim was to evaluate the application of the new guidelines from the International Consensus Meeting (ICM) in 2018 for diagnosis of PSI in this cohort.MethodsWe identified 17 patients with infection after shoulder arthroplasty between 2005 and 2014 who were treated with a two-stage revision and had a minimum follow-up of 5 years (range, 5-9 years). The mean time from the involved arthroplasty to first-stage revision was 40 months. All patients were revised to a reverse shoulder arthroplasty at second-stage revision. Complications, patient-reported outcomes (PROs), visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, Western Ontario Osteoarthritis of the Shoulder (WOOS) score, and range of motion (ROM) were noted. Patients were retrospectively scored and categorized using the ICM 2018 diagnostic criteria. Mean patient age was 64 ± 7 years, and 65% of patients were male.ResultsA recurrent infection developed in 3 (18%) of the 17 patients. The cumulative incidence of recurrence of infection was 0% at 1 year, 6% at 2 years, and 18% at 5 years. There were 6 (36%) other complications, including 4 periprosthetic fractures, 1 spacer fracture, and 1 dislocation. Two (12%) patients had scapular notching. At latest follow-up, patients who did not have recurrent infection had a statistically and clinically meaningful improvement from preoperative to postoperative PROs, including VAS for pain, ASES score, SST score, and WOOS score, and active ROM, including abduction and forward flexion. Using the ICM 2018 criteria at first-stage revision surgery, the category of PSI for 10 (59%) patients was “definite PSI,” 4 (23%) patients was “probable PSI”, and 3 (18%) patients was “possible PSI.”ConclusionThe rate of reinfection after a two-stage revision surgery for PSI at midterm follow-up was 18%. Clinical outcomes were favorable in the patients who remained free of infection. Further prospective study of the ICM criteria as they apply to making the diagnosis of infection in these patients would be beneficial.Level of evidenceLevel IV; Case Series; Treatment Study     

Does Margin Convergence Reverse Pseudoparalysis in Patients with Irreparable Rotator Cuff Tears?

BackgroundMargin convergence has been shown to restore muscle tension in a cadaveric model of a rotator cuff tear. However, the clinical utility of this technique remains uncertain for patients with pseudoparalysis caused by an irreparable rotator cuff tear.Questions/purposes(1) For patients with massive irreparable rotator cuff tears, in what proportion of patients does margin convergence reverse pseudoparalysis? (2) In patients with massive irreparable rotator cuff tears, does margin convergence improve American Shoulder and Elbow Surgeons (ASES) scores? (3) What is the survivorship free from MRI evidence of retear after margin convergence?MethodsBetween 2000 and 2015, we treated 203 patients for pseudoparalysis with a rotator cuff tear. Pseudoparalysis was defined as active elevation less than 90° with no stiffness, which a physical therapist evaluated in the sitting position using a goniometer after subacromial injection of 10 cc lidocaine to eliminate pain. Of those, we considered patients who underwent at least 3 weeks of unsuccessful nonoperative treatment in our hospital as potentially eligible. Twenty-one percent (43 of 203) who either improved or were lost to follow-up within 3 weeks of nonoperative treatment were excluded. A further 12% (25 of 203) were excluded because of cervical palsy, axillary nerve palsy after dislocation or subluxation, and development of severe shoulder stiffness (passive shoulder elevation < 90°). Repair was the first-line treatment, but if tears were considered irreparable with the torn tendon unable to reach the original footprint after mobilizing the cuff during surgery, margin convergence was used. When margin convergence failed, the procedure was converted to hemiarthroplasty using a small humeral head to help complete the repair. Therefore, 21% (42 of 203) of patients treated with regular repair (18% [36 of 203]) or hemiarthroplasty (3% [6 of 203]) were excluded. That left 93 patients eligible for consideration. Of those, 13 patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, and 86% (80 of 93) were analyzed (49 men and 31 women; mean age 68 ± 9 years; mean follow-up 26 ± 4 months). Seventy-six percent (61 of 80) were not evaluated in the last 5 years. We considered reversal of pseudoparalysis as our primary study outcome of interest; we defined this as greater than 90° active forward elevation; physical therapists in care measured this in the sitting position by using goniometers. Clinical outcomes were evaluated based on the ASES score from chart review, active ROM in the shoulder measured by the physical therapists, and the 8-month Kaplan-Meier survivorship free from MRI evidence of retear graded by the first author.ResultsPseudoparalysis was reversed in 93% (74 of 80) patients, and improvement in ASES scores was observed at the final follow-up (preoperative 22 ± 10 to postoperative 62 ± 21, mean difference 40 [95% CI 35 to 45]; p < 0.01). The 8-month Kaplan-Meier survivorship free from MRI evidence of retear after surgery was 72% (95% CI 63% to 81%). There were no differences in clinical scores between patients with and without retears (intact ASES 64 ± 24, re-tear ASES 59 ± 10, mean difference 6 [95% CI -5 to 16]; p = 0.27).ConclusionMargin convergence can be a good option for treating patients with pseudoparalysis and irreparable rotator cuff tears despite the relatively high retear rates. The proportion of pseudoparalysis reversal was lower in patients with three-tendon involvement. Further studies will be needed to define the appropriate procedure in this group.Level of EvidenceLevel IV, therapeutic study.