Failure rates and outcomes after anatomic total shoulder arthroplasty are equivalent irrespective of subscapularis repair technique

BackgroundSubscapularis management during total shoulder arthroplasty (TSA) remains an area of debate. Although subscapularis-sparing techniques exist, most TSAs are performed through a deltopectoral interval with the subscapularis released and repaired. A paucity of literature exists comparing transosseous repair (TOR) with direct primary tendon repair (PTR) of a subscapularis tenotomy. Our study compared outcomes after TOR and PTR in patients undergoing anatomic TSA.MethodsThis retrospective study included patients who underwent primary anatomic TSA through a deltopectoral approach with subscapularis tenotomy using either PTR or TOR for repair. Outcome measures included subscapularis failure rates, visual analog scale (VAS) scores, American Shoulder and Elbow Surgeons (ASES) survey scores, internal rotation range of motion and strength, complications, and reoperation rates at 3 months, 1 year, and 2 years.ResultsInstitutional database query identified 306 patients who had primary anatomic TSA, 114 of whom had PTR and 192 TOR. Postoperative ASES and VAS scores were significantly improved at all time points in both groups compared with the preoperative scores (P < .001). Average active internal rotation was significantly improved at all time points in the PTR group (P < .001). In the TOR group, significant improvement was noted at 1 and 2 years but not at 3 months. Overall, subscapularis failure occurred in 13 patients, and complications that did not require surgery were noted in 28 patients. Reoperation was performed in 18 patients. However, subscapularis failures, complications not requiring surgery, and reoperations were not significantly different between the two groups. The difference in average internal rotation range of motion between the TOR and PTR groups was statistically significant at 3 months (P = .015) but not at 1 year (P = .265), although the difference trended toward significance again at the 2-year mark (P = .080). No significant differences were noted between the two groups in internal rotation strength, VAS scores, and ASES averages.ConclusionBoth transosseous and primary soft-tissue repair techniques after subscapularis tenotomy result in good outcomes after primary anatomic TSA. No differences were found between groups regarding clinical subscapularis failure rate, internal rotation range of motion or strength, VAS, or ASES scores at 2-year follow-up.Level of evidenceLevel III, Retrospective Comparative Study     

Risk factors for instability after reverse shoulder arthroplasty

BackgroundInstability after primary reverse total shoulder arthroplasty (rTSA) is a rare but serious complication, potentially resulting in revision surgery. The causes of instability after rTSA are multifactorial and sometimes unknown. The goal of this study is to analyze an international database of one-platform shoulder prosthesis and conduct a logistic multivariate regression analysis to identify the factors associated with instability after primary rTSA and quantify the 2-year minimum clinical outcomes of patients with and without instability.MethodsA total of 5631 primary rTSA patients were analyzed from the international database of single rTSA prosthesis to quantify clinical outcomes at 2-year minimum follow-up for patients with and without instability. rTSA patients were divided into 2 cohorts based on if they were stable or unstable, and a subanalysis was conducted for patients who were unstable early (<6 months) and also unstable late (>6 months). For both stable and unstable rTSA patients, univariate and multivariate analyses were performed to quantify the patient, implant, and operative risk factors associated with instability after rTSA.ResultsFifty-five of the 5631 primary rTSA shoulders were reported to be unstable, with an overall instability rate of 0.98%. Female patients had an instability rate of 0.60% (21/3496), which was significantly lower (P < .0001) than the 1.63% instability rate for male patients (34/2085). Patients with subscapularis repair had an instability rate of 0.45% (10/2222), which was significantly lower (P = .0052) than the 1.17% instability rate of patients without a subscapularis repair (37/3161). Multivariate analysis identified numerous risk factors for instability, including younger age at the time of surgery, the use of cemented humeral fixation, larger glenosphere diameters, expanded/lateralized center of rotation glenospheres, and not repairing the subscapularis.DiscussionOur study demonstrated that patients with instability had significantly worse clinical outcomes, more pain, and worse function and range of motion as compared to rTSA patients who were stable. The univariate and multivariate analyses identified numerous patient, implant, and operative risk factors associated with instability. A patient with 1 or more of these identified parameters has an increased risk for instability, and that recognition is useful for patient counseling and consideration of repair of the subscapularis, when possible.     

Computer tomography assessment of the subscapularis after reverse shoulder arthroplasty and subscapularis repair: reduction in subscapularis size do not affect clinical outcomes

BackgroundExcellent Clinical and patient-reported outcome have been reported following Reverse Shoulder Arthroplasty (RTSA). However, outcomes in range of motion (ROM) remain variable. The role and importance of subscapularis repair during RTSA is a topic of intense debate and the long term-integrity of the subscapularis after repair remains poorly studied. Aims of this study were to radiologically evaluate pre- and postoperative condition of the subscapularis muscle in RTSA with concurrent subscapularis tendon repair using transosseous suture, and to investigate the correlation between clinical and radiological results.MethodsPatients who had undergone RTSA with subscapularis repair in our Institute between January 2010 and November 2016 were included. Constant, UCLA, Simple Shoulder Test and Visual Analog Scale (VAS) pain questionnaires were administered pre- and postoperatively. Internal rotation ability was recorded on a 6-point scale. Pre - and postoperatively shoulder CT scans were performed by a blinded examiner from which subscapularis muscle cross-sectional area (SMCSA) and supraspinatus fossa cross-sectional area (SFCSA) were measured in square millimeters. The SMCSA/SFCSA ratio was employed to standardize values for individual anatomical differences between patients.ResultsThe study included 32 patients (32 shoulders). Mean follow-up was 74.6 months ± 15.2 months (range 35–117 months). Statistically significant differences were found between pre- and postoperative VAS score, Constant Score, UCLA and Simple Shoulder Test scales (P < .0001). A postoperative SMCSA reduction of >35% was found in 38% of patients. Only 21% of patients maintained their preoperative SMCSA/SFCSA ratio. Overall, a statistically significant difference in pre and postoperative SMCSA/SFCSA ratios was found (P < .001). A correlation between radiological findings and clinical outcomes was not found.ConclusionPostoperative subscapularis size expressed as SMCSA and SMCSA/SFCSA ratio, was significantly reduced in the majority of patients treated with non-lateralized RTSA design and concurrent subscapularis tendon repair at final follow-up. A correlation between radiological findings and clinical outcomes was not found. RTSA with subscapularis tendon repair provides a high degree of patient satisfaction, as well as statistically significant improvements in clinical outcomes and internal rotation ROM. Being associated with several advantages, subscapularis repair may be routinely recommended.Level of evidenceLevel II; Prospective Cohort Design; Prognosis Study     

Treatment of massive irreparable rotator cuff tears without arthritis: a comparison of superior capsular reconstruction,partial rotator cuff repair,and reverse total shoulder arthroplasty

BackgroundTo compare outcomes of superior capsular reconstruction (SCR), partial rotator cuff repair (PR), and reverse total shoulder arthroplasty (rTSA) for massive irreparable rotator cuff tear (MIRCT) without arthritis at more than 2 years follow-up.MethodsA retrospective analysis of prospectively collected data of consecutive patients undergoing surgical treatment for intraoperatively confirmed MIRCT without arthritis using SCR, PR, or rTSA. Preoperative and postoperative data were collected and multivariate analysis performed.ResultsThirty two patients met inclusion criteria for SCR, 24 for PR, and 42 for rTSA (mean follow-up years: SCR 3.2; PR 4.0; rTSA 3.5; P = .02). The rTSA patients were older (66.2 years; SCR 57.3; PR 59.0; P = .0001) and more likely to be female (61.9%; SCR 12.5%; PR 25.0%; P < .001). Intraoperative evaluation demonstrated full thickness subscapularis tear in 37.5% for SCR, 4.2% for PR, and 21.4% for rTSA (P = .01). Pseudoparalysis was present in 18.8% of SCR, 0% of PR, and 14.3% of rTSA patients (P = .08). All groups saw postoperative improvement in strength and patient-reported outcomes (P < .036). SCR and rTSA demonstrated an improved forward elevation range of motion (ROM) postoperatively while PR did not (P = .96). No group experienced improvement in rotation ROM (P > .12). rTSA had worse postoperative ROM in all planes compared to SCR and PR (P < .003). There were no differences between groups in postoperative strength (P > .16) or patient-reported outcomes (American Shoulder and Elbow Surgeons P = .14; visual analog scale P = .86; single assessment numeric evaluation P = .61). Patients were satisfied in 81.2% of SCR cases, 87.5% of PR, and 95.3% of rTSA (P = .33). Three of 32 (9.4%) SCR patients required conversion to rTSA, while 3 of 24 (12.5%) PR patients required reoperation (2 revision repairs; 1 conversion to rTSA). There were 3 additional surgical complications among 42 rTSA patients (7.1%). There were 4 nonsurgical complications in the SCR group and 1 in the rTSA group. One SCR patient and 3 rTSA patients were deceased. Multivariate analysis demonstrated no independent predictors of revision surgery. An increased acromiohumeral interval distance was an independent predictor of improved postoperative strength for all groups (P < .02).ConclusionSCR, PR, and rTSA for the treatment of MIRCT without arthritis all significantly improved postoperative strength and outcomes scores with >80% patient satisfaction but with rTSA having worse postoperative motion and a higher complication rate. There were no independent predictors for revision surgery. SCR, PR and rTSA are all viable operations for MIRCT without arthritis with satisfactory results maintained at 2 years postoperatively.     

Transosseous tunnels versus suture anchors for the repair of acute quadriceps and patellar tendon ruptures: A systematic review and meta-analysis of biomechanical studies

BackgroundMultiple techniques have been developed for the repair of acute quadriceps and patellar tendon ruptures with the goal of optimizing clinical outcomes while minimizing complications and costs. The purpose of this study was to evaluate the biomechanical properties of transosseous tunnels and suture anchors for the repair of quadriceps and patellar tendon ruptures.MethodsA systematic review of the PubMed and Embase databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using specific search terms and eligibility criteria. Meta-analysis was performed by fixed-effects models for studies of low heterogeneity (I² <25%) and random-effects models for studies of moderate to high heterogeneity (I² ≥25%).ResultsA total of 392 studies were identified from the initial literature search with 7 studies meeting the eligibility criteria for quadriceps tendon repair and 8 studies meeting the eligibility criteria for patellar tendon repair. Based on the random-effects model for total gap formation and load to failure for quadriceps tendon repair, the mean difference was 8.88 mm (95% CI, −8.31 mm to 26.06 mm; p = 0.31) in favor of a larger gap with transosseous tunnels and −117.25N (95%CI, −242.73N to 8.23N; p = 0.07) in favor of a larger load to failure with suture anchors. A similar analysis for patellar tendon repair demonstrated a mean difference of 2.86 mm (95% CI, 1.08 mm to 4.64 mm; p = 0.002) in favor of a larger gap with transosseous tunnels and −56.34N (95% CI, −226.75 to 114.07N; p = 0.52) in favor of a larger load to failure with suture anchor repair.ConclusionsTransosseous tunnels are biomechanically similar to suture anchors for quadriceps tendon repair. Patellar tendon repair may benefit from reduced gap formation after cycling with suture anchor repair, but the load to failure for both techniques is biomechanically similar. Additional studies are necessary to evaluate these and alternative repair techniques.Level of evidenceSystematic review and meta-analysis of biomechanical studies, Level V.     

Anatomic versus reverse shoulder arthroplasty for post-traumatic sequelae of operatively and nonoperatively treated proximal humerus fractures

BackgroundThis study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF.MethodsA prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively.ResultsThere were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037).ConclusionFor treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management.Level of evidenceLevel III; Retrospective Cohort Design; Treatment Study     

Effect of the neck-shaft angle on stability in the onlay type of reverse shoulder arthroplasty: a cadaveric study

BackgroundAlthough reverse shoulder arthroplasty (RSA) has been indicated for treating patients suffering from cuff tear arthropathy, instability is a severe complication. The relationship between the humeral neck-shaft angle and joint stability in RSA as well as the clinical effect of subscapularis tendon repair on postoperative stability after RSA remain controversial. This study is primarily aimed to investigate the relationship between humeral neck-shaft angle and stability using the onlay type of RSA with preserved shoulder girdle muscles using fresh frozen cadavers. Moreover, we aimed to investigate the effect of subscapularis tendon repair after RSA placement.MethodsAn onlay type RSA of not-lateralized glenosphere in a massive rotator cuff tear model with preserved shoulder component muscles was placed on 7 fresh frozen cadavers, and traction tests were performed to dislocate by changing the neck-shaft angle of the stem to 135°, 145°, and 155°. The anterior dislocation force (DF) was evaluated in 6 patterns as follows: 2 patterns at 30° and 60° of abduction and 3 patterns at 30° of internal rotation, in neutral rotation, and 30° of external rotation. DF was recorded at neck-shaft angles of 135°, 145°, and 155° and with and without subscapularis tendon repair.ResultsAt 30° abduction, DF was significantly higher at a neck-shaft angle of 155° regardless of the rotational position (P < .05), and at abduction 60°, there was no difference in DF according to any rotational position and any neck-shaft angle. Regardless of the neck-shaft angle, the DF was significantly higher at 60° abduction than at 30° abduction (P < .05). Furthermore, the DF was significantly higher with subscapularis tendon repair (P < .01).ConclusionOur results showed some relationship between humeral neck-shaft angle and stability in the onlay type of RSA with preserved shoulder component muscles using fresh frozen cadavers. Moreover, a neck-shaft angle of 155° showed the highest anterior DF among neck-shaft angles of 135° and 145° at 30° abduction, and there was no difference at abduction 60° among any neck-shaft angle. Furthermore, subscapularis tendon repair also contributed to anterior stability.     

Effect of subscapularis repair in patients with an intact rotator cuff undergoing reverse total shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (rTSA) is increasing in popularity worldwide. There remains considerable debate as to whether to repair subscapularis or not following the procedure. Previous research into all indications demonstrates similar outcomes regardless of subscapularis (SSC) repair when using a medial glenoid/lateral humeral implant. The purpose of this study is to assess the effects of SSC repair on postoperative shoulder function and patient reported outcomes scores only in patients with an intact rotator cuff undergoing rTSA.MethodsPatients who underwent a primary rTSA for osteoarthritis with a minimum of 2 years follow-up were identified from an international shoulder registry. Patients with rotator cuff tears, cuff arthropathy, or post-traumatic arthritis were excluded. They were then divided into age and gender matched groups based on whether they had SSC repaired or not; 436 patients were analyzed in total, with 218 in each group. Numerous outcome measures between groups were compared, including active shoulder range of motion, complication rates, and 7 different patient reported shoulder outcome scores, using MCID (Minimal Clinically Important Differences), SCB (Substantial clinical benefit), and a 2 tailed paired T-Test.ResultsIn both groups, improvement in average shoulder movement and patient reported shoulder scores exceeded the threshold of SCB with 93% reporting their symptoms were better or much better in both groups. Those who had SSC repaired demonstrated a statistically significantly better mean active forward flexion (144° vs. 138°, P= .021) and mean internal rotation score (4.8 vs. 4.0, P= <.05), however these differences did not exceed the MCID where available. With regard to patient reported scores, those who had SSC repaired demonstrated a statistically significantly better mean Constant score (71 vs. 68, P= .05) and Shoulder Arthroplasty Smart Score (78 vs. 75, P= <.05), however these differences did not exceed the MCID for either score (5.3 and 6.1 respectively). There was no difference in complication rates between groups, including dislocation.ConclusionThis study demonstrates excellent results following rTSA with a medial glenoid/lateral humeral implant design regardless of whether the SSC was repaired or not. For the majority of patient reported scores and shoulder movements there was no significant difference between SSC repaired and nonrepaired groups, and where statistically significant differences were noted, the difference did not exceed the MCID in any measure.Level of EvidenceLevel III; Retrospective Comparative Study     

A biomechanical evaluation of three surgical techniques for subscapularis repair

This study was designed to determine which subscapularis repair method performs best under fatigue loading. Fresh-frozen human cadaveric shoulders were used. A standard circumferential release was performed, including a rotator interval release and separation of the subscapularis from the anterior and inferior capsules. One of 3 methods was used to repair the subscapularis tendon: tendon-to-tendon, tendon-to-bone, or bone-to-bone using a buttress plate. The shoulder was mounted on a fatigue-testing machine, and the medial end of the subscapularis tendon was attached to a soft-tissue clamp. We initially tested each specimen for fatigue at 150 N for 500 cycles, then at 300 N for 2500 cycles. The failure rate of bone-to-bone and tendon-to-tendon repairs was significantly better than that of the tendon-to-bone repair. The bone-to-bone repair exhibited the best combination of repair strength and restoration of subscapularis length.     

Impact of tobacco use on perioperative complications and readmission rates following primary anatomic and reverse total shoulder arthroplasty

BackgroundThe purpose of this study is to investigate the relationship between tobacco use and outcomes following both aTSA and rTSA, with the hypothesis being that tobacco users will have inferior postsurgical outcomes compared to nontobacco users.MethodsThe Nationwide Readmission Database (NRD) was queried from 2016 to 2018 to identify qualifying cases of aTSA (n = 16,241) and rTSA (n = 23,975). These groups were further subdivided based on tobacco use status. Demographic and hospital characteristics were first compared between groups. The unadjusted incidence of postoperative medical and shoulder-specific complications, mortality, revisions, and readmissions were then compared. Finally, the groups were assessed for the same variables after controlling for demographic factors and comorbidities.ResultsFor both aTSA and rTSA, statistically significant differences exist in regard to age, sex, primary expected payer, median household income, hospital region, hospital teaching status, and total number of comorbidities between tobacco users and nonusers (all P < .05). Tobacco users undergoing aTSA experienced higher rates of gastrointestinal complications (0.07% vs. 0.01%, P = .021) and readmissions (15.3% vs. 13.6%, P = .007), while tobacco users undergoing rTSA experienced higher rates of acute renal failure (2.5% vs. 1.9%, P = .005), acute respiratory distress (1.3% vs. 0.9%, P = .002), and the need for ventilator assistance (1.2% vs. 0.7%, P < .001). Adjusted analysis showed that tobacco users were more likely to develop acute respiratory distress syndrome (OR = 1.292, P = .036) and require ventilator assistance (OR = 1.376, P = .008), and are more likely to have at least one readmission (P = .026).ConclusionThe results of this study demonstrate that tobacco users undergoing primary aTSA and rTSA are at an increased risk for several perioperative complications and are more likely to be readmitted following surgery compared to nontobacco users. These findings highlight the importance of determining a patient's tobacco use status as consideration should be given to not performing a TSA until tobacco use has stopped.Level of evidenceLevel III; Retrospective Cohort Treatment Study     

Prospective observational study of anatomic and reverse total shoulder arthroplasty using a single implant system with long-term follow-up

BackgroundBoth anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are the standard of care for various end-stage degenerative conditions of the glenohumeral joint. The purpose of this prospective study was to compare clinical outcomes of aTSA and rTSA using the same platform total shoulder arthroplasty system at a minimum follow-up of 8 years.MethodsAn international multicenter data registry was used to identify patients undergoing primary aTSA or rTSA with a minimum of 8-year follow-up. Patients were scored preoperatively and at latest follow-up using 6 outcome and 4 range of motion metrics. Patients graded global shoulder function on a 0-10 scale. Patient satisfaction was classified as much better, better, unchanged, or worse. Pain was graded using the Visual Analog Scale. A student’s 2-tailed paired t-test, Chi-squared test, or Wilcoxon rank-sum test were used when appropriate, where P < .05 indicates significant differences.ResultsA total of 364 aTSA patients and 278 rTSA patients were included. rTSA had greater mean age (aTSA 65.1, rTSA 71.2, P < .0001) and shorter mean follow-up (aTSA 115.2 months, rTSA 109.7 months; P = .0002). Postoperatively, all patients demonstrated significant improvements in pain and function. Preoperatively, aTSA patients had greater active abduction and forward elevation, global function, Constant Score, and the University of California, Los Angeles score. At latest follow-up, aTSA had greater active abduction, forward elevation, external rotation, and Simple Shoulder Test scores. There were no postoperative differences in patient satisfaction, shoulder function, pain, or any other outcome measure between the groups. aTSA patients had a greater revision rate (aTSA 5.8%, rTSA 1.8%; P = .0114), with no difference in complication rates. Humeral radiolucent lines were present in 20.9% of aTSA patients and 37.1% of rTSA patients (P = .0011). Glenoid radiolucent lines were present in 48.0% of aTSA patients (average score of 1.5). Scapular notching was present in 14.5% of rTSA patients (average grade of 0.26).ConclusionThis study is one of the largest to date that compares aTSA and rTSA with a minimum follow-up of 8 years. Significant improvements are seen in both aTSA and rTSA. For both groups, the complication rate was lower than previously reported in the literature. At the latest follow-up, pain relief and global function were significantly improved with high patient satisfaction in both groups, with no statistical differences found. This study provides physicians with information to help guide them when advising patients as to what they can expect at a minimum of 8 years after aTSA and rTSA.     

Early repair of complete atrioventricular septal defect has better survival than staged repair after pulmonary artery banding: A propensity score–matched study

ObjectivesComplete atrioventricular septal defect (cAVSD) repair is usually performed between 3 and 6 months of age. However, some children present with early heart failure requiring intervention. It is unclear whether primary complete repair or initial pulmonary artery banding (PAB) provides better outcomes.MethodsAll patients (n = 194) who underwent surgery for cAVSD younger than 3 months of age between 1990 and 2019 were included. Propensity score matching was performed on risk factors for mortality.ResultsPrimary complete repair was performed in 77.8% (151/194), whereas PAB was performed in 22.2% (43/194). Children who had PAB were younger (P < .01), had lower weight (P < .001), and less trisomy 21 (P = .04). Interstage mortality for PAB was 18.6% (8/43), whereas early mortality for primary repair was 3.3% (5/151). Survival at 20 years was 92.0% (95% confidence interval [CI], 85.6%-95.7%) for primary repair and 63.2% (95% CI, 42.5%-78.1%) for PAB (P < .001). There was no difference in left atrioventricular valve (LAVV) reoperation rates (P = .94). Propensity score matching produced 2 well-matched groups. Survival at 20 years was 94.2% (95% CI, 85.1%-98.8%) for primary repair, and 58.4% (95% CI, 33.5%-76.7%) for PAB (P = .001). There was no difference in LAVV reoperation rates (P = .71). Neonatal repair was achieved with no early deaths and 100% survival at 10 years.ConclusionsIn children younger than 3 months of age, complete repair of cAVSD is associated with better survival than PAB. Both strategies have similar rates of LAVV reoperation. Neonatal repair of cAVSD can be achieved with excellent results. Primary repair of cAVSD should be the preferred strategy in children younger than 3 months of age.     

Outcomes following quadriceps tendon repair using transosseous tunnels versus suture anchors: A systematic review

IntroductionTwo major techniques are used to repair complete quadriceps tendon ruptures, transosseous tunnel (TT) and the suture anchor (SA). There are multiple studies comparing the biomechanical outcomes of repairs performed with TT or SA. Our purpose was to compare the clinical outcomes following quadriceps tendon repair using SA and TT fixation techniques.MethodsThree major search engines were used with predetermined keyword searches to perform a systematic review of literature. These studies were independently scanned by two reviewers using PRISMA criterion. All included studies had to include at least one of the following outcome measures: range of motion (ROM), Lysholm score, complications, and/or re-ruptures.ResultsUsing three major search engines, 1039 articles were identified. After removing duplicates and screening for inclusion, 49 articles were reviewed. Two independent reviewers searched the studies to meet the inclusion criteria, and eight studies were selected. These eight studies included 156 knees in the TT group and 54 knees in the SA group. The TT group had a significantly better ROM after QT repair (132.5° versus 127.0°, p = 0.02). There was no significant difference in Lysholm scores between the TT group (92.6) and SA group (91.0, p = 0.11). There were significantly more complications in SA groups (9.3% versus 1.3%, p = 0.013), but not a significant difference in re-rupture rate between those undergoing SA vs. TT repair (3.7% versus 0%, p = 0.065). The SA group had a significantly higher age at time of surgery (63.62 vs. 54.32)ConclusionThe current study suggests that, following quadriceps tendon rupture, there are no significant differences in functional outcome between TT and SA techniques. Those undergoing TT repair attained a statistically significantly greater final ROM but this difference may not be clinically relevant. There was a statistically significantly higher rate of post-operative complications using SA technique.     

Primary fixation strength of rotator cuff repair techniques: a comparative study

Purpose:The goal of the study was to compare the primary fixation strength of transosseous suture, suture anchor, and hybrid repair techniques for rotator cuff repair.Type of Study:Animal model experiment.Methods:Thirty-two sheep shoulders were divided into 4 homogeneous groups, according to bone density and tendon dimensions. Infraspinatus tendons were transected from their insertions and reattached using 4 different techniques. Group 1 was repaired with a single Mason-Allen stitch and 2 transosseous tunnels for each end of the suture, knotted on the lateral cortex of proximal humerus; group 2 was repaired with double Mason-Allen stitches and 2 transosseous tunnels; group 3 was repaired with 2 Corkscrews (Arthrex, Germany); and group 4 was repaired with 2 Corkscrews combined with a single Mason-Allen transosseous suture. All specimens were tested for their fixation strengths with a material testing system.Results:The mode of failure in group 1 was mainly suture breakage. In groups 3 and 4, the tendons pulled out from the sutures. In group 2, sutures broke the bony bridge between the 2 tunnels. The mean load to failure value was 160.31 ± 34.59 N in group 1, 199.36 ± 11.73 N in group 2, 108.32 ± 15.98 N in group 3, and 214.24 ± 28.52 N in group 4. Anchor fixation was significantly weaker compared with other groups (P <.001). Combination of a transosseous suture and anchor fixation (group 4) was significantly stronger than the single transosseous suture (group 1) and double anchor techniques (group 3) (P <.001).Conclusions:Hybrid technique was the strongest among the tested rotator cuff repair techniques. With the addition of one transosseous suture to two anchors, the strength of the repair could be doubled.     

Acute versus delayed reverse total shoulder Arthroplasty for the management of Proximal Humerus Fractures

ObjectivesProximal humerus fractures (PHF) are common, yet their optimal management remains debated. Reverse total shoulder arthroplasty (rTSA) is an increasingly popular option, particularly for non-reconstructible or osteoporotic fractures. Despite this trend, current literature provides limited guidance with regards to surgical timing and patient selection for rTSA. A trial of non-operative management might be beneficial for many patients who are not clearly indicated for surgery, provided this does not have a major negative impact on results for those who ultimately require rTSA. The purpose of this study was to investigate whether delayed reverse shoulder arthroplasty for fracture (>28 days from injury) is associated with any difference in complication rates or functional outcomes relative to acute surgery.DesignRetrospective cohort studyPatients/Participants114 consecutive patients who underwent rTSA as the primary management of a PHF at two Level 1 trauma centers and one academic community hospital between 2004 and 2016.InterventionrTSA as primary management of proximal humerus fractureMain Outcome MeasurementsComplications, range of motion, and patient-reported functional outcomes scores (DASH, PROMIS physical function, and EQ-5D)ResultsEighty-two of 114 patients (72%) underwent early surgery. Complex (4-part, head-split, dislocated) fractures were significantly more common in the acutely treated group. There was no significant difference in complications. Overall complication rate was 11.4%. There was a significant difference in DASH score favoring early surgery, with an average score of 22.4 in acutely treated patients versus 35.1 in delayed patients (p = 0.034). There was a non-statistically significant trend towards better PROMIS physical function scores and ROM in the acutely treated group.ConclusionDelay in performing primary rTSA for management of PHF does not lead to an increase in complication rates but it may come at the cost of worse functional outcomes in patients who ultimately require rTSA.     

Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision

PurposeTo present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success.MethodsRecords of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation.ResultsA total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression).ConclusionHypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision.Level of evidenceTreatment study, level IV     

Comparison of patient demographics and patient-related risk factors for dislocations following reverse shoulder arthroplasty

BackgroundDislocations following primary reverse total shoulder arthroplasty (rTSA) are a feared and concerning complication. With the increasing number of reverse total shoulder arthroplasty (rTSA) procedures being performed worldwide e, studies evaluating risk factors for dislocation following this procedure are limited. The purpose of this study was to utilize a large claims database to identify patient-related risk factors associated with dislocations following primary rTSA.MethodsA retrospective query of the Part A and Part B 100% Medicare Standard Analytical Files (SAF) claims database was performed identifying patients who underwent primary rTSA for the treatment of glenohumeral osteoarthritis. The inclusion criteria for the study group consisted of all patients who had a dislocation within 2-years following the index procedure. Patients with a record of other arthroplasty-type procedures were excluded. The query yielded 30,670 patients with (n = 703) and without (n = 29,967) dislocations. Multivariate binomial logistics regression analysis was performed to calculate odds (OR) on the impact of patient-related risk factors for dislocations following primary rTSA. A P value less than .002 was considered statistically significant.ResultsStudy group patients that sustained a dislocation following primary rTSA were generally younger than the age of 65 (16.8 vs. 8.3%) and male (59.6 vs. 38.8%). Study group patients had a higher comorbidity burden, as demonstrated by higher mean Elixhauser-Comorbidity Index (ECI) scores (9 vs. 6, P < .0001). The greatest risk factors for dislocations included being male (OR: 3.06, P < .0001), opioid use disorder (OR: 1.74, P = .0007), hypertension (OR: 1.56, P = .001), morbid obesity (OR: 1.43, P < .0001), electrolyte and fluid derangements (OR: 1.29, P = .0001), and depressive disorders (OR: 1.23, P = .0001).ConclusionAs the number of primary rTSA procedures increase worldwide, identification of patient-related risk factors for dislocations is of great importance. The study showed the greatest risk factors for dislocations included male sex with modifiable risk factors being opioid use disorder, hypertension, and morbid obesity. The study is vital as it can facilitate in guiding orthopedists and altering management for these high-risk patients.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.     

Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures

IntroductionThe role of deltoid ligament repair is controversial in the treatment of bimalleolar equivalent ankle injuries. Our purpose was to compare midterm functional outcomes and reoperation rates of unstable distal fibula fractures treated with open reduction internal fixation (ORIF) of the fibula and either deltoid ligament repair, trans-syndesmotic fixation, or combined fixation.MethodsSkeletally mature subjects were retrospectively identified after fixation of isolated unstable distal fibula fractures treated at a single academic level 1 hospital from January 2005 to May 2019. The AAOS Foot and Ankle Module outcomes questionnaire (AAOS-FAM) was obtained at a mean time from surgery of 4.6 +/- 3.1 years. Subjects underwent one of three methods of fixation including distal fibula ORIF and one of the following: trans-syndesmotic fixation (N = 66), deltoid ligament repair (N = 16), or combined trans-syndesmotic fixation and deltoid ligament repair (N = 26). Outcomes scores and Charlson Comorbidity Index scores were compared between groups by Kruskal-Wallis testing for non-normally distributed data. Rates of reoperation were compared by Fisher's exact test. Statistical significance was set to P < 0.05 for all comparisons.ResultsThere was no significant difference in AAOS-FAM scores between the three groups (P = 0.18). No subjects in the deltoid ligament repair group underwent reoperation compared to 17 (26%) in the trans-syndesmotic fixation group and six (23%) in the combined fixation group. The most common reason for reoperation was removal of hardware, which was performed in 12 (18%) subjects in the trans-syndesmotic fixation group and three (12%) subjects in the combined fixation group.ConclusionsDirect deltoid ligament repair yields similar functional scores and fewer reoperations compared to trans-syndesmotic fixation at midterm follow up. Deltoid ligament repair may be a favorable treatment strategy when considering trans-syndesmotic fixation in the surgical treatment of unstable distal fibula fractures.     

Reverse shoulder arthroplasty for proximal humeral fractures: better clinical midterm outcome after primary reverse arthroplasty versus secondary reverse arthroplasty after failed ORIF in the elderly

BackgroundJoint replacement surgery as a treatment for complex proximal humeral fractures is an established option, especially in the elderly. In light of the increased attention to reverse total shoulder arthroplasty (rTSA), this study has analyzed the outcomes of patients with primary reverse arthroplasty and after secondary reverse arthroplasty for failed osteosynthesis.MethodsWe retrospectively reviewed 57 patients with an average age of 76 years (min. 55; max. 94; SD 7) from 2010 and 2015 who underwent primary rTSA (30) and secondary rTSA after the failure of plate osteosynthesis (27) after proximal humeral fractures. The functional outcome of the operated shoulder was evaluated by clinical scores (Constant-Score, ASES, DASH and Oxford), range of motion (RoM), pain and activity level.ResultsPrimary rTSA had a significantly better functional outcome, mean-follow-up 37.3 months, measured by Constant-Score (57.13 vs 45.78 points; p= .015) compared to secondary RTSA, mean follow-up 42.1 months. A significantly better active abduction (P= .002), forward flexion (P = .003) and internal rotation (P = .037) was observed in the primary rTSA group, especially in the follow-up > 35 months.ConclusionReverse shoulder arthroplasty is an effective treatment for proximal humeral fractures as primary or revision surgery. The reliable clinical outcome especially in the follow-up to 40 months after primary reverse arthroplasty may suggest to prefer rTSA for complex humeral fractures in the elderly.Level of evidenceLevel III; Retrospective comparative study