Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years

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

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

Objectives: Rotator cuff tears (RCTs) are the number one cause of shoulder pain and are becoming increasingly common as the population ages. The increasing incidence of RCTs present a significant economic burden, with shoulder pain being the No. 1 cause of disability in the United States. Repair of RCTs, in return, result in a cumulative $3.4 billion savings annually in the United States. Historically, follow-up for rotator cuff repair (RCR) mirrors that of hip and knee arthroplasty, with minimum of 2-year outcomes reported in most peer-reviewed studies. Recent literature, however, demonstrates no significant increase in clinically significant improvement after 6 months regarding functional outcomes and patient-reported outcomes (PROs) such as American Shoulder and Elbow Surgeons Shoulder Score (ASES), visual analog scale (VAS), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores among others. The purpose of this study is to demonstrate degradation of outcome improvement in patient-reported outcomes after 1-year follow-up of RCR. We hypothesize that there will be no clinically significant increase in Single Assessment Numeric Evaluation (SANE) scores after 1 year postoperatively. The primary outcome of interest is change in SANE score over the 2-year episode of care. Methods: All patients that underwent primary RCR within a single health care system were eligible for inclusion in this study. Exclusion criteria included history of surgery on the affected shoulder, incomplete PROs at baseline, 1 year, or 2 years postoperatively, and concomitant fractures about the affected shoulder. Patient demographics, injury characteristics, and operative technical characteristics were obtained through review of the patients’ electronic medical records and operative reports. PROs included SANE, ASES, and VAS scores and were collected prospectively, then stored in a HIPAA-compliant database until reviewed retrospectively for this study. An anchor-based minimum clinically important difference (MCID) was calculated for the study cohort at 1 and 2 years postoperatively and was anchored on a 1-point increase in the Patient-Reported Outcomes Measurement Information System global 10 quality of life question. The primary outcomes of interest are baseline (preoperative), 1-year, and 2-year SANE scores. Secondary outcomes of interest included rates of symptomatic retear, reoperation, and revision. Statistical analysis was performed with a statistical analysis software (Intellectus). Analyses included descriptive statistics, t tests, chi-square tests of independence, Fischer exact tests, and analyses of variance, as appropriate. Statistical significance was defined as an alpha value of p ≤ 0.05. Results: A total of 495 patients met criteria for inclusion in the study (Table 1). The average age of the study population was 61.5 ± 8.4 years old, and the average body mass index (BMI) was 29.9 ±5.5. Most patients were men (287, 58.0%). A total of 24 patients were under workers’ compensation. Other medical comorbidities of interest included diabetes (74, 15.0%), depression (85, 17.2%), anxiety (74, 15.0%), and rheumatoid arthritis (6, 1.2%). Just over half of patients had chronic tears as described by the surgeon in clinical notes or operative reports (259, 52.3%), and most patients had full-thickness tears documented in the operative report (402, 81.2%). The most common adjuvant procedures included subacromial decompression (SAD) (419, 84.6%), biceps tenodesis (211, 42.6%) and distal clavicle excision (DCE) (133, 26.9%). Baseline SANE scores for the study cohort averaged 40.8 ± 20.3 with a subsequent of 43.4 within the first year postoperatively, bringing the 1-year SANE average to 84.1 ± 196 (p < 0.001). After the 1-year follow-up, however, there was small but statistically significant change in SANE scores with the 2-year SANE scores averaging 87.5 ± 18.1, p < 0.001) (Figure 1). One-year anchor-based MCID for SANE was found to be 45.5, with 238 (48.1%) meeting this MCID. At 2-years, 213 patients (43.0%) met the MCID of 50.6. Conclusions: Over the 2-year episode of care following primary RCR, patients saw an overall increase in SANE of 46.8. Even after the 1-year follow-up, patients continued to see statistically significant increases in SANE scores; however, they did not see clinically significant increase in PROs, as demonstrated by fewer patients meeting the 2-year MCID compared with the 1-year MCID. [Figure: see text]

Patients with chronic kidney disease can expect significant improvement in pain and function after shoulder arthroplasty

High correlation but limited agreement: reassessing the stand-alone use of the Single Assessment Numeric Evaluation score compared to American Shoulder and Elbow Surgeons score after rotator cuff repair.

Background: Biceps tenodesis has been suggested as a superior surgical technique compared with isolated labral repair for superior labral anterior-posterior (SLAP) tears in patients older than 35 years. The superiority of this procedure in younger patients, however, is yet to be determined. Purpose: To compare the outcomes of arthroscopic SLAP repair with those of arthroscopic-assisted subpectoral biceps tenodesis for type II SLAP tears in active-duty military patients younger than 35 years. Study Design: Cohort study; Level of evidence, 3. Methods: Preoperative and postoperative evaluations with a minimum 5-year follow-up including the visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) shoulder score were administered, and scores were compared between 2 groups of patients younger than 35 years. One group included 25 patients who underwent SLAP repair, and the second group included 23 patients who underwent arthroscopic-assisted subpectoral biceps tenodesis. Results: The preoperative patient age (P = .3639), forward flexion (P = .8214), external rotation (P = .5134), VAS pain score (P = .4487), SANE score (P = .6614), and ASES score (P = .6519) did not vary significantly between the 2 study groups. Both groups demonstrated statistically significant increases in function as measured by the ASES and SANE and decreases in pain as measured by the VAS at a minimum of 5 years postoperatively. Also at a minimum of 5 years postoperatively, patients in the tenodesis group had lower pain (1.3 vs 2.6, respectively; P = .0358) and higher SANE (84.0 vs 63.3, respectively; P = .0001) and ASES (85.7 vs 75.4, respectively; P = .0342) scores compared with those in the repair group. Failure rate was 20.0% in the repair group versus 0.0% in the tenodesis group (P = .0234). Conclusion: Active-duty military patients younger than 35 years with type II SLAP tears had more predictable improvement in pain, better functional outcomes, and lower failure rates after biceps tenodesis compared with SLAP repair for type II SLAP tears. Overall, the results of this study indicate that arthroscopic- assisted subpectoral biceps tenodesis is superior to arthroscopic SLAP repair for the treatment of type II SLAP tears in military patients younger than 35 years.

ObjectivesRisk factors for anterior shoulder dislocation include young age, contact activities and male sex. The influence of sex on patient-reported outcomes of arthroscopic Bankart repair (ABR) is unclear, with few...

Objectives: Rotator cuff tears are the most common cause of shoulder disability, most commonly affecting the middle-aged population. Treatment for rotator cuff tears has changed dramatically over the past few decades, with overall volume of rotator cuff repairs (RCRs) increasing by approximately 1.6% each year. Simultaneously, there has been a shift from open, inpatient RCR to arthroscopic, outpatient procedures. Currently, well over 75% of patients undergo arthroscopic repair. The two most common techniques for rotator cuff fixation include single- or double-row fixation. Cadaveric and biomechanical studies demonstrate more complete reduction of the rotator cuff to its original footprint with double row repair, with a subsequent increase in anatomic restoration and biomechanical advantage. Many studies regarding clinical and functional outcomes, however, have not consistently demonstrated statistically significant differences between the two. The purpose of this study is to determine differences in patient-reported outcomes (PROs) after single- and double-row rotator cuff repairs at one and two years postoperatively. We hypothesize that single-row RCR will have noninferior clinical and patient-reported outcomes when compared to the double-row RCR cohort over the 2-year episode of care. Primary outcomes include baseline, 1-year and 2-year postoperative Single Assessment Numeric Evaluation (SANE) scores. Methods: All patients within a single health system that underwent primary rotator cuff repair between 2016 and 2022 were eligible for inclusion in this study. Exclusion criteria included incomplete baseline PROs, involvement of infraspinatus, subscapularis or teres minor tendons, revision surgeries, and concomitant fractures of the shoulder. Demographic information including age, sex, BMI, ASA score, injury characteristics and medical comorbidities were obtained through review of the patients’ electronic medical record. Surgical characteristics and technique were obtained from operative notes. PROs were collected prospectively and stored in a HIPAA-compliant electronic database until retrospective review for this study. Primary outcomes of interest include SANE score at baseline, 1-year and 2-years postoperatively. Secondary outcomes of interest included American Shoulder and Elbow Surgeons (ASES) scores, Patient-Reported Outcomes Measurement Information System (PROMIS) global 10 health questionnaire scores, rates of symptomatic retear and reoperation. Statistical analysis included descriptive analyses, paired t-tests, chi-squared test of independence and one-way ANOVA as appropriate. Statistical significance was defined as an alpha value of p ≤ 0.05. Results: A total of 237 patients met criteria for inclusion in this study, the majority of which were female (122, 51.5%). The average BMI was 30.0 ± 5.6, and the average age of the study participants was 59.0 ± 9.4 years. The majority of patients underwent double-row RCR (134, 56.5%). There were no significant differences in age, BMI, ASA score, gender, or smoking status between the two groups (Table 1). There was a higher observed frequency of diabetes mellitus than expected in the double-row cohort, however this did not reach statistical significance (p = 0.066). There was no significant difference in symptomatic retear, revision RCR, and other reoperation rates between the two cohorts (Table 2). The cohort that received double-row repair had a higher observed frequency of full-thickness tears than expected (p <0.001), however there was no significant difference in the observed frequencies of chronic and acute tears between the two cohorts. Baseline ASES scores did not differ significantly between the two cohorts (p = 0.505). Both cohorts saw statistically significant increase in ASES scores from baseline to 1-year (Figure 1). The difference between 1-year and 2-year ASES scores was less than a quarter of the improvement seen in the first year postoperatively, however, was still statistically significant in the double-row cohort and neared statistical significance in the single-row cohort (p = 0.048 and p = 0.075, respectively). While both cohorts saw significant improvement in ASES scores over the 2-year period, there was no significant difference in score change between the two cohorts. The baseline SANE scores were 40.7 ± 20.6 and 43.2 ± 21.4 for the double and single-row cohorts respectively. Each cohort saw statistically significant increases in SANE scores at 1 year postoperatively and continued to see significant increase between 1- and 2-years postoperatively (Figure 1). There was no statistically significant difference between the two cohorts regarding 1- and 2-year change in SANE scores. Conclusions: Over a 2-year period of care after RCR, patients saw significant improvement in SANE and ASES scores, with the majority occurring in the first year postoperatively. There were no statistically significant differences in patient-reported outcomes between patients that underwent double- and single-row repairs. Single- and double-row RCRs perform comparably over a 2-year episode of care, with excellent clinical and patient-reported outcomes. [Figure: see text]

Background:Superior labrum from anterior to posterior (SLAP) lesions represent a significant cause of shoulder pain and disability among active duty members of the US military. However, few data exist regarding the surgical management of type VIII SLAP lesions.Hypothesis:We hypothesized that arthroscopic repair would decrease pain and increase function at the midterm follow-up and allow for a high rate of maintenance of active duty status.Study Design:Case series; Level of evidence, 4.Methods:Consecutive active duty military patients were identified from January 2011 through June 2015 who underwent arthroscopic repair of type VIII SLAP lesions performed by a single surgeon. Patients were excluded if they underwent glenoid microfracture, other capsulolabral repair, or rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up: pain visual analog scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, and Rowe instability score.Results:A total of 30 patients met the inclusion criteria for the study. The mean ± SD follow-up was 96.60 ± 10.91 months. At final follow-up, the mean visual analog scale score improved from 8.17 ± 1.6 to 1.63 ± 1.90 (P < .0001), the Single Assessment Numeric Evaluation score from 41.65 ± 16.78 to 87.63 ± 13.02 (P < .0001), the American Shoulder and Elbow Surgeons score from 36.47 ± 10.26 to 88.07 ± 13.94 (P < .0001), and the Rowe score from 35.33 ± 6.56 to 90.00 ± 14.68 (P < .0001). Three patients reported postoperative complications, and 1 progressed to further surgery. Overall, 90% of patients remained on active duty military service and were able to return to preinjury levels of work and recreational activity. The failure rate, defined as persistent instability or activity-limiting pain, was 10%.Conclusion:The results of this study demonstrated favorable outcomes for the majority of patients after arthroscopic repair of type VIII SLAP lesions at midterm follow-up, supporting repair as a viable treatment option for type VIII SLAP tears in this patient population.

Objectives:Lateral epicondylitis is the most common condition affecting the elbow however conservative treatment for the condition remains controversial. Various approaches have been described including braces, physical therapy, corticosteroid injections, and platelet-rich-plasma (PRP) injections. PRP is taken from a centrifuged blood sample and consists mainly of platelets and growth factors. Although research surrounding injections in lateral epicondylitis continues to evolve, randomized controlled trials have shown that PRP injections are associated with decreased pain at two-year follow-up. Visual analog scale (VAS) pain scores and other patient reported outcome measures (PROMs) such as Disabilities of the Arm, Shoulder, and Hand (DASH) have been used previously; however, no studies to date have used the Single Assessment Numeric Evaluation (SANE). It was hypothesized that patients would report improvements in pain and function at four weeks and four months after PRP injection. The primary outcomes were SANE and VAS pain scores. The secondary aim was to determine a minimum clinically important difference (MCID) value for SANE for this procedure.Methods:This was a retrospective review of a prospectively collected PROM database from 2021-2023. All patients who received a PRP injection for lateral epicondylitis were included in this study. Patients were excluded if they were missing baseline SANE or VAS pain scores, received an injection anywhere besides the common extensor tendon origin, or had overlapping conditions such as cervical radiculopathy, cubital tunnel or carpal tunnel syndrome. Baseline patient characteristics including sex, age, smoking history, history of depression or anxiety, disease chronicity, and hand dominance were collected. Previous history of physical therapy, corticosteroid injection, PRP injection, and procedure characteristics including milliliters (ml) of PRP injected and number of fenestrations were also collected. All PRP injections were ultrasound guided and conducted using the health-system standardized protocol with leukocyte-rich plasma. Primary outcomes included SANE and VAS pain scores at baseline, four weeks, and four months post-injection. MCID was calculated using the distribution-based method, calculated as half of the standard deviation of the change in SANE score. Additional outcomes included if the patient experienced any adverse events following injection, underwent subsequent injection within the study period.Results:A total of 36 patients met criteria for analysis. More than half the patients were male (n=20, 55.6%), and the average age was 50.15±9.31 years. Only 5.6% of patients were current smokers (n=2). Fifteen patients (41.7%) had histories of depression, and 10 patients (27.8%) had histories of anxiety. Most patients received an injection after experiencing symptoms for 10.62±9.56 months on average. The majority of patients previously tried or were concurrently going to physical therapy (n=28, 77.8%). Fourteen patients (38.9%) had received a previous corticosteroid injection, and five patients (13.9%) had received a previous PRP injection.The injection procedure typically consisted of 2.36±0.66 ml of PRP with 5.74±3.03 fenestrations. Most injections were done in the dominant arm (n=28, 77.8%). A total of six patients went on to have a repeat injection (16.7%). There were five patients who experienced increased post-procedure pain (13.9%) and one who experienced nerve irritation (2.8%). All adverse events eventually resolved.SANE scores at baseline, four-week, and four-month follow-up were 53.06±23.28, 57.22±27.32, 65.19±27.07. The difference between baseline and follow-up at four weeks was not statistically significant (p=0.245), but the follow-up scores at four months were found to be statistically higher than baseline scores (p=0.044). The average changes from baseline to four weeks and baseline to four months were 7.04±30.77 and 15.50±28.13, respectively. VAS pain scores at baseline, four-week, and four-month follow-up were 5.14±2.10, 4.25±2.66, 3.17±2.81. Follow-up scores at four weeks and four months were found to be statistically lower than baseline scores (p=0.006, p=0.003). The average changes from baseline to four weeks and baseline to four months were -1.29±2.29 and -2.44±2.99, respectively. A history of prior corticosteroid injection was not significantly associated with changes in SANE scores at four weeks or four months after PRP injection (p=0.149, p=0.602, respectively). The SANE MCID values at four weeks and four months were 15.39 and 14.07, respectively. Of those patients who reported, 44.4% met the four-week value and 37.5% met the four-month value.Conclusions:Patients after PRP injection for lateral epicondylitis demonstrated increased SANE scores at four months and decreased VAS pain scores at four weeks and four months. The change in SANE scores at four weeks was not statistically significant. These results may indicate that there are greater pain reducing effects as well as milder extremity functionality improvement effects associated with PRP injection. This may be in part due to the inherent nature of the disease with the more prevalent symptom being pain over loss of function. PRP injections are a safe and effective conservative treatment method for reducing pain symptoms and increasing functionality in patients with lateral epicondylitis. Physicians should discuss patient expectations for improvement during the early post-injection period.

Early repair of traumatic rotator cuff tears improves functional outcomes.

Severe Obesity Is Not Associated With Worse Functional Outcomes Following Arthroscopic Rotator Cuff Repair

Is stemless total shoulder arthroplasty indicated in elderly patients?

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

The Constant-Murley (Constant) score, Western Ontario Osteoarthritis of the Shoulder (WOOS) index, American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) score are commonly used to assess patient-reported function following shoulder surgery. However, psychometric properties for these tools are mostly unknown for patients with primary glenohumeral arthritis who have undergone anatomic total shoulder arthroplasty (TSA). The purposes of this study were to (1) compare the responsiveness and internal validity between the 4 patient-reported outcomes (PROs) and (2) identify PRO score values associated with patient satisfaction after TSA. A total of 234 primary TSAs were performed for primary glenohumeral osteoarthritis with a 2-year or greater follow-up. The Constant score, WOOS index, ASES score, SANE score, and patient satisfaction were assessed preoperatively and 2 to 5 years postoperatively. Effect sizes, standardized response means, and relative efficiency were calculated to determine responsiveness, and internal validity was determined via the presence of floor and/or ceiling effects. Receiver operator characteristic (ROC) curves were constructed to identify the minimum outcome score that could correctly identify a satisfied patient. At final follow-up, 88% of patients were satisfied. The PROs had large effect sizes and standardized response means (≥0.83). The minimum score that most correctly identified a patient as satisfied was 78 for ASES score, 18 for WOOS index, 73 for Constant score, and 58 for SANE score. However, the ASES score, WOOS index, and SANE score had marked postoperative ceiling effects, whereas the Constant score was the most responsive and internally valid tool. These results suggest that the Constant score should serve as the primary PRO for patients with primary glenohumeral arthritis, whereas the WOOS index, ASES score, and SANE score could be supplementary assessments. [Orthopedics. 2017; 40(3):e513-e519.].