American Shoulder And Elbow Society Score Research Articles

Long-term Functional and Pain Outcomes Following Arthroscopic Partial-Thickness Rotator Cuff Tear Completion and Repair

Objective: There remains little consensus on the optimal treatment approach for partial-thickness rotator cuff tears and few studies have examined the long-term outcomes of different surgical repair techniques. The purpose of this study is to identify the long-term functional and pain outcomes of arthroscopic tear completion followed by repair. The authors hypothesize that this technique will allow patients to have long-term pain relief and return to a pre-injury level of function. Methods: Patients (n=16) who underwent arthroscopic tear completion and repair for a partial-thickness rotator cuff tear were included in this case series. Each patient returned for a one-time follow-up visit, with an average follow-up time of 7.09 years, at which time physical and neurological exams were performed, quality of life was assessed through subjective questionnaires, American Shoulder and Elbow Society (ASES) and the University of California at Los Angeles (UCLA) shoulder scores were obtained, and magnetic resonance imaging was performed. Results: The average ASES score was 85.3, with 81% of patients reporting that they were able to return to a pre-injury level of function. Half of the patients reported the highest possible UCLA shoulder score of 35. Physical examination showed that patients had excellent strength and range of motion. Magnetic resonance imaging demonstrated continuity of the repair in all but one patient. However, 25% of patients reported return of symptoms since surgery, including pain and limited mobility. Conclusion: At an average of 7.09 years follow-up, most patients were found to have full mobility, pre-injury level of activity, and maintenance of rotator cuff integrity in the surgically treated shoulder. However, one fourth of patients reported return of symptoms. The authors conclude that the tear completion and repair technique can lead to long-term functional improvement, but has less favorable results in terms of subjective pain level and quality of life.

SHOULDER AND ELBOW FUNCTION FOLLOWING ANTEGRADE HUMERAL NAILING AND PLATE FIXATION IN MIDDLE THIRD HUMERAL SHAFT FRACTURES

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively.A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained.One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction.This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability.

Outcomes of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture Versus Rotator Cuff Arthropathy.

Reverse total shoulder arthroplasty (RSA) is used to treat a variety of shoulder-related pathologies. This study compared medium-term clinical outcomes of less than 10-year follow-up in patients treated with RSA for proximal humerus fracture (PHF) versus rotator cuff arthropathy (RCA). This retrospective review was conducted at two tertiary care centers, in which self-reported clinical outcomes were assessed using four validated instruments, that is, American Shoulder and Elbow Society (ASES) score, Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS), and shoulder subjective value (SSV). Statistical analyses were performed using linear or logistic regression with generalized estimating equations. Of the 189 patients included in this study, 70 were treated for fracture and 119 for RCA. At a mean postoperative follow-up of 6.4 years, the means were 79.7 for ASES score, 20.8 for SPADI-Total, 0.8 for VAS, and 77.1 for SSV. After adjusting models for covariates, there was no significant difference in average SSV (P = 0.7), VAS (P = 0.7) or SPADI-Pain (P = 0.2) between PHF and RCA cohorts; however, the RCA cohort reported significantly better outcomes in ASES scores (P = 0.002), SPADI-Disability (P < 0.0001), and SPADI-Total (P = 0.0001). Patients with RCA and PHF treated with RSA achieved similar medium-term outcomes in several domains, particularly postoperative pain levels; however, patients with PHF reported greater perceived disability. RSA is an effective pain-controlling procedure, but patients may have variable functional outcomes based on the indication for surgery.

Are Vascularized Fibula Autografts a Long-lasting Reconstruction After Intercalary Resection of the Humerus for Primary Bone Tumors?

A vascularized fibula graft (VFG) is the vascular autograft most frequently used to restore large segmental long bone defects, particularly in the upper limb. Because the use of a vascularized fibula involves an operation in an uninvolved extremity with potential morbidity, it is important to document that this type of reconstruction is successful in restoring function to the humerus. However, the long-term results of VFG after intercalary resection of the humeral diaphysis for bone tumors are still unknown. (1) What was the complication rate of reconstruction? (2) What was the functional result after surgical treatment, as assessed by the Musculoskeletal Tumor Society (MSTS) score, the American Shoulder and Elbow Society (ASES) score, and Constant score? (3) What was the survivorship of these grafts free from revision and graft removal at 5, 10, and 15 years? Between 1987 and 2021, 127 patients were treated at our institution with en bloc resection for a primary malignant or an aggressive benign bone tumor of the humerus; we excluded patients treated with extra-articular resection or amputation. Of those, 14% (18 of 127) were treated with intercalary resection of the humeral diaphysis for primary bone tumors and reconstruction with VFG, with or without a bulk allograft, and were analyzed in this retrospective study. Generally, our indications for reconstruction with VFG are intercalary resection of the humerus for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands, in whom adequate bone stock of the proximal and distal epiphysis can be preserved. In 13 patients, VFG was used alone, whereas in five patients, a massive allograft was used. Our policy was to use VFG combined with a massive allograft in patients undergoing juxta-articular joint-sparing resections in which proximal osteotomy was performed close to the anatomic neck of the humerus to obtain more stable fixation and better tendinous reattachment of the rotator cuff and deltoid. All 18 patients who were treated with a VFG were available for follow-up at a minimum of 2 years (median follow-up 176 months, range 26 to 275 months), and although three have not been seen in the past 5 years and are not known to have died, they had 172, 163, and 236 months of follow-up, and were included. The median age at surgery was 25 years (range 2 to 63 years), the median humeral resection length was 15 cm (range 8 to 21 cm), and the median fibular length was 16 cm (range 12 to 23 cm). Complications and functional scores were ascertained by chart review that was performed by an individual not involved in patient care. Functional results were assessed with the MSTS score (range 0 to 30), the ASES score (range 0 to 100), and the Constant score (range 0% to 100%). Survivorship was estimated using a Kaplan-Meier survivorship estimator, which was suitable because there were few deaths in this series. Seven patients underwent a revision procedure (one radial nerve transient palsy because of screw impingement, four nonunions in three patients with one humeral head avascular necrosis, treatment for screw-related pain in one patient, and two VFG fractures), and one patient underwent VFG removal. Donor site complications were observed in four patients (one ankle valgus deformity and three claw toes-the first toe in two patients and the other toes in the third). At the final clinical control, at a median follow-up of 176 months (range 26 to 275 months), the median MSTS score was 30 of 30 (range 28 to 30), the median ASES score was 98.3 (range 93 to 100), and the median Constant score was 93.5% (range 79% to 100%). Revision-free survival was 71% (95% CI 53% to 96%) at 5 years and 57% (95% CI 37% to 88%) at 10 and 15 years; VFG removal-free survival was 94% (95% CI 83% to 100%) at 5, 10, and 15 years. VFG appears to be an effective reconstructive option after humeral intercalary resection for primary bone tumors. These are complex procedures and should be performed by an experienced team of surgeons who recognize that complications may occur frequently in the first years after the procedure. The frequency of mechanical complications observed in the first 5 years postoperatively may be lessened by using long spanning-plate fixation, and if successful, this reconstruction provides a long-term, durable reconstruction with excellent functional results. Level IV, therapeutic study.

Assessment of the Arthroscopic Double-Row Restoration Technique's Reliability and Operational Results for Shoulder Cuff Reconstruction

Objective: This study aims at evaluating the effectiveness of shoulder cuff restoration by arthroscopic surgery in dual row repair mode and shows 30 months of practical results, an ASES-based scoring system was developed. Methods: This study was conduced at mayo hospital Lahore in orthopedics department and the duration of this study was from October 2021 to march 2023. 23 patients who had significant rotator cuff tears repaired arthroscopically in a double-row fashion are included in this cross-sectional research. The operating surgeon performed a clinical assessment on patients who had been admitted for surgery in the outpatient setting both before and after surgery, as well as during follow-up visits at six weeks, three months, six months, and one year. The last examination took place on average 30 months after surgery. Using a scoring system based on a modified ASES score, the function of the patient was evaluated both preoperatively and postoperatively, and the results were compared. Based on the Modified American Shoulder and Elbow Society (ASES) score, a patient-rated questionnaire was utilized to assess shoulder and elbow function. Three parts make up the questionnaire, the first of which included questions regarding pain and had six components with a total weight of 30 points. The existence of pain, its location, and if the patients had discomfort at night were all questions that were posed to the patients. A visual analog pain scale from 0 to 10 was used to assess the degree of the patient’s pain as well as their usage of drugs. The second phase, which included 10 components and a weighted average of 50 points, examined candidates' capacity to carry out everyday tasks. On a scale of 0 to 5, patients were asked to assess their level of competence to accomplish tasks while accounting for any challenges they may have encountered. The shoulder instability was evaluated in the last portion using a visual analog scale with a range of 0 to 10. Patients were divided into four groups based on the grading system: Excellent result (score &gt;75), Good outcome (score 50-75), Fair outcome (score 25-50), and Poor outcome (score &lt; 25) Results: At the time of the last follow-up, there was a substantial improvement in the mean operational result scores depending on the Patient Self-Assessed Questionnaire (p-value &lt; 0.01). By using magnetic resonance imaging to evaluate repair integrity 12 months after surgery, it was discovered that 16 patients had type-I repairs, 2 patients had type-II repairs, and only 1 patient had type-III repairs. For enormous tears, the study's retear rate was 5%. Comparing the type-III repaired shoulders to the other kinds of repaired shoulders, the type-III repaired shoulders showed substantially worse functional outcomes in terms of total scores and strength (p-value &lt; 0.01). Practical Implication: In the practical implication of this study we discovered that the arthroscopic double-row restoration approach is a successful treatment for repairing large rotator cuff injuries with a low chance of re-tear and a big increase in activity levels. Conclusions: In this research, we discovered that the arthroscopic double-row restoration approach is a successful treatment for repairing large rotator cuff injuries with a low chance of re-tear and a big increase in activity levels. Keywords: double-row technique, restoration, shoulder cuff, arthroscopically, resonance imaging

Open Subpectoral Tenodesis for Isolated Traumatic Long Head of Biceps Tendon Rupture Provides Excellent Functional Outcomes in Active Male Patients.

For many years the long head of biceps tendon (LHBT) rupture has been described and is commonly identified by weakness, cramping, and the so-called "Popeye" sign. Traditionally, this was treated non-operatively, likely reflecting patient factors and the technical difficulty in reattaching a degenerative and shortened tendon. In contrast, traumatic distal biceps rupture is now commonly repaired despite historically being managed non-operatively. The advent of a convenient and reproducible surgical technique led to an increase in the rate of fixation, thereby improving the cramping and weakness associated with non-operative treatment. Given recent surgical advances within this field, many techniques are now present for LHBT pathology. We describe results from a cohort of patients suffering traumatic LHBT rupture who sought a surgical solution to improve their symptoms. Over four years, 18 male patients underwent surgical intervention for isolated traumatic LHBT rupture. The technique used involved an open subpectoral tenodesis with fixation of the LHBT into the bicipital groove. Postoperative immobilization using a sling was recommended for six weeks prior to a progressive rehabilitation program. Patients were assessed with pre- and postoperative visual analog scores (VAS) for pain and American Shoulder and Elbow Society (ASES) scores. The mean patient age at the time of surgery was 49 years (range: 26-65 years). The mean time to surgery was nine weeks (range: 2-24 weeks). All patients showed an improvement following surgery with a mean pre-op ASES score of 33 (range: 10-60) compared to a post-op score of 92.6 (range: 85-100). All patients were able to return to work and sport, with all but one returning to the same functional demand level of work. The mean pre-op pain VASwas 6.3 (out of 10) compared to 0.2 post-op. All patients had a requirement for analgesia pre-operatively and none had postoperatively. No surgical complications were observed. No correlation was observed between the time to surgery and the outcome. LHBT rupture is often treated non-operatively as few studies within the literature describe the surgical technique and outcomes from surgical intervention. When treated non-operatively, patients complain of pain, cramping, and cosmetic deformity known as the "Popeye" sign. Following a traumatic rupture of the LHBT, we have demonstrated excellent outcomes using a standard approach and common fixation technique that has the potential to improve the functional outcome for symptomatic patients. Open subpectoral biceps tenodesis is associated with excellent outcomes in symptomatic patients following isolated LHBT rupture.

Comparison of Extracorporeal Shock Wave Therapy and Ultrasound-Guided Shoulder Injection Therapy in Patients with Supraspinatus Tendinitis.

The present study compared the clinical effect of extracorporeal shock wave therapy (ESWT) with that of ultrasound (US)-guided shoulder steroid injection therapy in patients with supraspinatus tendinitis. We hypothesized that the two treatments would show comparable results. The inclusion criteria were age over 20 years and diagnosis of supraspinatus tendinitis using US. Ultimately, 26 patients were assigned using blocked randomization: 13 in the US-guided shoulder injection group and 13 in the ESWT group. Treatment outcomes were evaluated using the pain visual analog scale (pVAS), the American Shoulder and Elbow Society (ASES) score, and the Constant score at baseline and at 1 and 3 months after the procedure. At 1 month after the intervention, pVAS, ASES, and constant score were significantly higher in the US-guided shoulder injection group than in the ESWT group, but not at 3 months after the intervention. Both groups showed clinically significant treatment effects at 3 months after the intervention compared to baseline. No significance was shown using equivalence testing. US-guided shoulder injection therapy was not superior to ESWT therapy. Considering the complications and rebound phenomenon of steroid injections, interventions using ESWT may be a good alternative to treat patients with supraspinatus tendinitis.

Comparison of Treatment Options of Three- and Four-Part Humerus Proximal Fractures in Patients Over 50 Years of Age.

IntroductionOur aim was to evaluate different treatment methods including conservative treatment (CT), locking-plate osteosynthesis (OS) and hemiarthroplasty (HA) in three- and four-part humeral fractures in patients older than 50 years.MethodsForty-seven patients that have at least one year of follow-up were divided into three groups: 18 patients treated with OS, 14 patients treated conservatively and 15 patients treated with HA. For further evaluation, constant shoulder score, disabilities of the arm, shoulder and hand score (DASH), American Shoulder and Elbow Society (ASES) score had been used. Shoulder range of motion was also assessed.ResultsOS and CT groups had better scores than HA group. In OS group, average Constant score was 71.6 ± 16.2, DASH score was 12.1 (5.2-24.2) and ASES score was 77.5 (50.8-96.6). In CT group, average Constant score was 69.6 ± 19.2, DASH score was 16.4 (12.5-36.7) and ASES score was 76.6 (45.4-87.9). DASH scores (p = 0.032), Constant scores (p = 0.001), forward elevation (p < 0.001), abduction (p < 0.001), internal (p = 0.022) and external rotation (p = 0.048) were significantly improved in OS and CT groups than HA group.ConclusionsHA should not be considered a priority in surgical planning in Neer three-part and four-part proximal humerus fractures. CT is superior for patients with additional morbidity and advanced age. But in patients who are younger and can tolerate the surgical procedure, the priority should be OS.

Arthroscopic repair versus open surgical techniques for the management of recurrent anterior shoulder instability: A comparative study

Background: Surgical shoulder stabilization has been shown to reduce the risk of recurrence with some authors recommending intervention even after a single dislocation. The present study compared arthroscopic repair versus open surgical techniques for the management of recurrent anterior shoulder instability. Materials & Methods: 50 patients of anterior shoulder instability of both genders were divided into 2 groups of 25 each. Group I comprised of patients managed with arthroscopic method and group II with open surgery. Modified Rowe score and ASES (American Shoulder and Elbow Society) score were recorded. Results: The mean ROWE pain score at 4 weeks was 3.0 and 3.4 in group I and II respectively, at 6 weeks was 5.4 and 5.0 in group I and II respectively, at 9 weeks was 10.2 and 5.8 in group I and II respectively and at 12 weeks was 10.1 and 9.2 in group I and II respectively. The mean ASES pain score at 4 weeks was 2.6 and 1.3 in group I and II respectively, at 6 weeks was 4.3 and 2.5 in group I and II respectively, at 9 weeks was 2.8 and 2.0 in group I and II respectively and at 12 weeks was 3.2 and 3.0 in group I and II respectively. The difference was non- significant (P> 0.05). Conclusion: Both techniques were observed to be equally effective in the management of cases of recurrent anterior shoulder instability.

Stephen S. Burkhart, M.D. Shoulder Innovation Research Award Paper: Balloon Subacromial Spacer vs. Partial Repair for Massive Rotator Cuff Tears: A Randomized Trial

Limited options exist for the treatment of massive rotator cuff tears (MRCTs). Surgical repair may be technically challenging and require prolonged rehabilitation with variable outcomes. The present study was designed to assess the safety and efficacy of an arthroscopically-deployed inflatable biodegradable subacromial spacer balloon (InSpaceTM, OrthoSpace, Israel) as an alternative to partial repair in patients with MRCTs. A non-inferiority, prospective, single-blinded, multicenter, randomized, controlled, pivotal study was conducted to compare the outcomes of arthroscopic subacromial balloon spacer implantation to partial repair in the treatment of MRCTs. Patients ≥ 40-years of age with full thickness MRCTs (≥ 5 cm, ≥ 2 tendons) were included. Baseline and follow-up data were collected to identify patients that had reached a primary composite endpoint consisting of the minimal clinically important difference (MCID) for the Western Ontario Rotator Cuff (WORC) score (275 points) and American Shoulder and Elbow Society (ASES) score (6.4 points) by 6-weeks and maintained at 12-months without subsequent secondary surgical intervention (SSSI) or serious adverse device effects (SADEs). 184 patients were randomized, 176 (88/group) of which completed the required 12-month follow-up per protocol. At 12-months, 45 (51%) patients in the spacer implant group and 35 patients (39.8%) in the partial repair group, had reached and maintained the primary composite endpoint, corresponding to a difference between groups of 11.4% (non-inferiority margin 10%; p = 0.0049). Additionally, the spacer implant group demonstrated superior improvement (p = 0.0224) when evaluating the following combined efficacy timepoints of ASES score at 6-weeks and WORC score at 12-weeks, both maintained at 12-months in the absence of SSSI or SADEs, compared to the partial repair group. Arthroscopic subacromial balloon spacer implantation is a viable alternative to partial repair in the treatment of symptomatic MRCTs with comparable clinical outcomes at one year.

Comparative study between open and arthroscopic surgical techniques in the management of recurrent anterior instability of the shoulder

Background: Present study was done to compare the effectiveness i.e. range of motion and incidence of failure rates, recurrence and pain of arthroscopic repair versus open surgical techniques for the management of recurrent anterior shoulder instability. Materials and Methods: Institution based open-label, comparative clinical study was done at Medical College and Hospital, Kolkata between March 2016 to August 2017 (1.5 years). Based on the result of a similar previous study, a sample size of 15 in each group was calculated. Therefore, 15 cases of anterior shoulder instability treated by arthroscopic method and 15 cases treated by open surgery have been selected for study. Inclusion criteria were patient with soft tissue Bankart’s lesion, bony Bankart’s lesion, humeral avulsion of glenohumeral ligament (HAGL), anterior labral posterior sleeve avulsion (ALPSA), glenoidlabrum and articular disruption and capsular stretch and injury. Study tools were used like Modified Rowe score, ASES (American Shoulder and Elbow Society) score and Goniometer. Operative techniques were used like arthroscopic capsulolabral repair and latarjet procedure. Results: About 14 (93.3%) patients were negative in bony apprehension test in arthroscopic technique. Approximately 15 (93.8%) patients were positive in bony apprehension test in Open technique. Association between bony apprehension test in two groups was not statistically significant (p difference was found between according to CT scan report in two groups (p=0.30910). Mean Rowe pain was significantly higher according in arthroscopic technique compare to open technique at 6W and 9W follow-up period. Mean Rowe stability was significantly higher according in arthroscopic technique compare to open technique at 6W and 9W follow-up period. Conclusion: Both arthroscopic and open surgical methods are utilized for management of anterior glenohumeral instability. The use of arthroscopy has increased significantly in today’s practice an

Early Follow-Up of Arthroscopic Latarjet Procedure with Screw or Suture-Button Fixation for Recurrent Anterior Shoulder Instability.

ObjectiveTo evaluate the early clinical and radiographic results of arthroscopic Latarjet procedure using screw or suture‐button fixation in patients with recurrent anterior shoulder dislocation.MethodsTwelve patients who underwent arthroscopic Latarjet procedure between January 2015 and December 2018 at our institution were retrospectively studied. Data of the patients' history, including age, gender, side of affected arm, body mass index (BMI), and the number of dislocations since fist dislocation were collected. Preoperative and postoperative clinical follow‐up data were evaluated using Walch–Duplay score, American Shoulder and Elbow Society (ASES) score, and modified Rowe score. Active external rotation and active internal rotation at 90° of abduction as well as active elevation were evaluated preoperatively and postoperatively. The position and healing condition of the transferred coracoid bony graft were also assessed using computed tomography (CT) and Mimics 19.0 software.ResultsMean follow‐up was 24.9 months (range, 13 to 53 months) of all patients. At final follow‐up, the average ASES score (preoperative vs postoperative values) had improved from 68.9 ± 7.9 to 91.1 ± 6.1 in screw fixation group and 68.9 ± 8.9 to 87.5 ± 6.7 in suture‐button fixation group; the average Rowe score (preoperative vs postoperative values) had improved from 25.0 ± 8.4 to 92.5 ± 4.2 in screw fixation group and 21.7 ± 13.7 to 93.3 ± 4.1 in suture‐button fixation group; the average of Walch–Duplay score (preoperative vs postoperative values) had improved from 12.5 ± 15.1 to 91.7 ± 4.1 in screw fixation group and 18.3 ± 20.7 to 88.3 ± 7.5 in button fixation group. The forward flexion was 175.0° ± 8.4° preoperatively and 178.3° ± 4.1° postoperatively in screw fixation group while 174.8° ± 10.2° preoperatively and 175.0° ± 5.5° postoperatively in suture‐button fixation group. The active external rotation was 77.5° ± 5.2° preoperatively and 71.7° ± 4.1° postoperatively in screw fixation group while 72.5° ± 6.9° preoperatively and 68.3° ± 7.5° postoperatively in suture‐button fixation group. The average of active internal rotation was 66.7° ± 6.1° preoperatively and 67.5° ± 6.1° postoperatively in screw fixation group while 68.3° ± 11.3° preoperatively and 66.7° ± 7.5° postoperatively in suture‐button fixation group. In postoperative CT scan, 91.7% grafts midline center were located at or under the equator in the en face view; 75% of the bone blocks were flush to the glenoid face in the axial view, with only two grafts exhibiting slight medial placement in screw fixation group (33.3%) and one graft exhibiting slight lateral placement in suture‐button fixation group (16.7%). All grafts achieved bone union. Graft absorption mostly occurred outside of the “best‐fit” circle. The average bony absorption rates of the coracoid grafts were 25.2% and 10.18% in screw fixation group and suture‐button fixation group, respectively, at 6 months postoperative follow‐up.ConclusionBoth suture‐button fixation and screw fixation techniques in arthroscopic Latarjet procedure revealed excellent clinical outcomes with low complication rates in the early follow‐up. The suture‐button fixation exhibited a flexible fixation pattern that allowed for self‐correction to some extent, even slight lateralization could finally remodel over time.

Why Do Patients Decide to Have Surgery for Their Symptomatic Rotator Cuff Tear? A Prospective Study

Objectives:While rotator cuff pathology may be amenable to conservative therapy, patients with full thickness tears not improving with non-operative treatment are indicated for repair. The decision to undergo surgery is often multifactorial with pain, loss of function, and concern for progression all factoring in the decision-making process. The purpose of this investigation was to evaluate patients main determining factors in deciding to have surgery for their rotator cuff tear, correlate these factors with strength of surgeon recommendation and clinical outcomes.Methods:One hundred and fifty patients undergoing arthroscopic rotator cuff repair (ARCR) were enrolled prospectively. Patients received a questionnaire preoperatively to determine why they decided to proceed with surgical repair. This 13-question survey was developed based on evidence-based review of rotator cuff repair literature and the Delphi technique. Patients were asked to rate each factor with regard to importance in their decision to proceed with repair. Surgeons were given a similar Likert Scale and were queried on how strongly they would recommend surgery for their patients based upon various factors such as MRI findings, age, etc. Pre- and post-operative shoulder function was assessed with the American Shoulder and Elbow Society (ASES) Score. Descriptive statistics were used to evaluate the reasons to proceed with surgery and correlated with outcomes based on ASES scores.Results:The most influential patient reported factors for proceeding with surgical repair were: limited functionality of the shoulder (81%), surgeon recommendation (80%), and daily chronic pain (77%). Patients improved from 42.6 to 77.0 on the ASES from baseline to 6-months (p<0.001). Patients who listed that they were unable to play a favorite sport or hobby as their top reason for surgery demonstrated a significant increase in their ASES score relative to other factors at the 3 month time point (p=0.0014); otherwise, there was no significant difference in outcomes for any other time point based on category importance. Subgroup analysis of males and females and older v. younger patients demonstrated significant findings. Females were more likely to proceed with repair due to inability to sleep and daily, chronic pain (p<.005) relative to males. Younger patients were more likely to proceed with repair for the inability to play a sport/hobby and increased demands of work relative to older patients (p<.005). There was no correlation between any decision factor and final outcome of ASES scores. Younger patients and male patients both demonstrated higher baseline ASES scores (p<.05); however, there was no difference in outcome measures at final follow-up.Conclusion:Prior studies have shown that rotator cuff repair is best at alleviating pain for full thickness rotator cuff tears and may not be as impactful for improving function. Despite this evidence, the majority of patients undergoing rotator cuff repair in our study did so to improve function of their shoulder. While pain, inability to sleep, and inability to participate in ones favorite hobby/sport were important to our patient population, a strong surgeon recommendation had no correlation with our patients decision to proceed with repair. Surgeons should be mindful of these differences between gender and age when counseling patients pre-operatively. Outcomes of ARCR do not appear to be determined by pre-operative decision making on the part of the patient.

Latissimus Dorsi Tendon Transfer with or Without Superior Capsular Reconstruction for Treatment of Irrepairable Rotator Cuff Tears

Objectives:Treatment options for massive irreparable rotator cuff tears, in middle aged adults, consists of tendon transfer or superior capsular reconstruction (SCR). The purpose of this study was to evaluate if transfer of the latissimus dorsi tendon transfer is enhanced with combination of superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.Methods:At a single institution, all consecutive patients undergoing transfer of the latissimus dorsi tendon with or without superior capsular reconstruction, between 2013 and 2016, for treatment of irreparable rotator cuff tears were evaluated. SCR, was indicated, in addition to latissimus transfer, for patients with impaired preoperative active abduction. All clinical notes, diagnostic imaging, and operative reports were reviewed in detail. Demographics, operative techniques, and radiographic parameters were collected and measured. Functional outcome scores were prospectively collected from patients. The primary outcome of the study was the Disability of Arm, Shoulder, Hand (DASH) score. The secondary outcomes of the study were the Visual Analog Scale (VAS) pain score, Single Assessment Numeric Evaluation (SANE) score, and the American Shoulder and Elbow Society (ASES) score.Results:At 3 years, there were a total of 26 latissimus dorsi tendon transfers performed in patients with irreparable rotator cuff tears. Of these, 8 patients underwent only latissimus dorsi tendon transfer and 18 patients underwent latissimus dorsi tendon transfer combined with a superior capsular reconstruction. Average age was 53 years old with the majority of patients being male (88%). The dominant extremity was involved in 22 (85%) of latissimus transfers and 14 (53%) of patients had previous surgery to address a rotator cuff tear. Follow-up, for the entire cohort, was on average 29 months. At final follow-up, there was no significant difference in physical examination or radiographic measurements between patients with latissimus transfer alone and those with latissimus transfer with SCR. All patients, undergoing either technique, showed significant improvement in both the DASH score (preoperative DASH=59.6, postoperative DASH=39.9, P=0.049) and VAS score (preoperative VAS=6.6, postoperative VAS=3.3, P=0.0006). However, those patients undergoing revision surgery, regardless of technique, showed significantly less improvement in the DASH score (P=0.005), VAS score (P=0.002), SANE score (P=0.005), and the ASES score (P=0.001). Transfer of the Latissimus tendon with SCR, in comparison to only tendon transfer, did not show any significant difference in the final DASH score (p-value=0.72). At the same time, there was no significant difference between latissimus transfer, with or without SCR, in the secondary outcomes of the VAS score(P=0.97), the SANE score(P=0.63), or the ASES score (P=0.74).Conclusion:This is the first study to report the outcomes of latissimus dorsi tendon transfer with superior capsular reconstruction in comparison to only latissimus dorsi tendon transfer for treatment of irreparable rotator cuff tears. The study suggests that transfer of the latissimus dorsi tendon in combination with superior capsular reconstruction, at short term follow-up of 2 years, may not significantly influence functional outcome. Rather, patients undergoing revision surgery, regardless of technique, may demonstrate smaller improvements in functional outcomes.Table 2.Range of Motion & Physical Examination in Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8) Lat + SCR (n=18) Preoperative Postoperative P-Value Preoperative Postoperative P-Value Range of Motion (Active) Abduction135 ± 21.276.4 ± 180.0475.4 ± 26.071.5 ± 220.80Forward Flexion106.9 ± 36.7135.7 ± 32.20.15103.5 ± 32.2110.6 ± 45.40.35External Rotation36 ± 11.442.9 ± 150.8025.3 ± 18.638.5 ± 16.30.04Internal Rotation65 ± 22.959.3 ± 12.40.5554.4 ± 13.363.1 ± 13.00.08Hornblower Sign2 (25%)2 (25%)0.9814 (78%)2 (11%)0.07External Rotation Lag6 (75%)2 (25%)0.3417 (94%)3 (17%)0.01Continuous data are reported as mean ± standard deviation. Categorical data reported as number (%).Table 4.Functional Outcomes at Final Follow-Up of Latissimus Dorsi Tendon Transfer with/without SCR Lat Only (n=8) Lat + SCR (n=18) Mean (Std Dev)Mean (Std Dev)P-Value Primary Outcome DASH47.0 ± 39.842.5 ± 27.50.72 Secondary Outcome Vas3.14 ± 3.53.4 ± 3.50.97SANE54.7 ± 38.560.9 ± 22.10.63ASES65.8 ± 36.360.6 ± 30.90.74Constance63.8 ± 31.050.3 ± 23.30.34

Clinical and Radiological Outcome after Surgical Treatment in Displaced Clavicular Midshaft Fracture

Background: The first purpose of this study is to compare the clinical and radiological outcomes of surgical treatment for displaced midshaft clavicle fracture (Robinson type 2B1 vs. 2B2) with 3.5-mm low profile clavicular locking compression plate. The second purpose is to evaluate the difference of the results depending on the presence of accompanying injuries. Methods: Forty-nine patients who underwent an operation for the fractures were reviewed retrospectively. Fracture patterns were classified according to group 2B1 and 2B2 using Robinson’s classification. For radiological outcome, time to union after operation was evaluated and for clinical outcome, American Shoulder and Elbow Society (ASES) score, University of California in Los Angeles (UCLA) score, visual analogue scale (VAS), and range of motion (ROM) were evaluated from preoperative period to last follow-up period. Results: The mean time for union was not significantly different in the 2B1 group and 2B2 group (p=0.062). No statistically significant difference in ASES score, UCLA score, and VAS was observed between 2B1 and 2B2 (p=0.619, p=0.896, p=0.856, respectively). In ROM, significant higher mean forward flexion and abduction was observed in 2B2 (p=0.025, p=0.017, respectively) and there was no difference in external rotation and external rotation at shoulder 90o abduction position (p=0.130, p=0.180, respectively). There was no significant difference in clinical outcomes according to the accompanying injuries. Conclusions: There was no difference in clinical and radiological outcome between Robinson 2B1 and 2B2 type fracture after the operation. Accompanying injuries may not affect the clinical result of displaced midshaft clavicle fractures.

A preformed antibiotic-loaded spacer for treatment for septic arthritis of the shoulder

Total shoulder arthroplasty infections are rare, depending on the use of antibiotic prophylaxis, the local blood supply, the axial load gradient and the proximal location of the shoulder. The purpose of this study was to evaluate the results of treatment for infections in total shoulder arthroplasty and septic arthritis using a preformed antibiotic-loaded spacer. Seven shoulders in as many patients were treated for infected arthroplasty or septic arthritis without previous surgery. A preformed antibiotic-loaded spacer was always applied. Patients were evaluated at the final follow-up with the Constant Score (CS), the Secec Elbow Score (SES), and the American Shoulder and Elbow Society Score (ASESS). The mean follow-up was 40, 71 months after spacer implant. Infection was always confirmed preoperatively by the leukocyte and neutrophil counts in the aspirated synovial fluid, and intra-operative biopsy and pathologic analysis. Positive bacterial cultures were found in 5 cases: 3 MRSA and 2 Staphylococcus epidermidis. The mean SES increased from 34.43 before spacer implant to 77.29 at final follow-up, ASESS ranged from 14.86 to 21.14, and CS from 40.28 to 79.14. A preformed antibiotic-loaded spacer is intended to release gentamicin alone, but we can consider adding vancomycin to increase antibiotic spectrum. An early diagnosis and an immediate treatment can prevent a persistent infection and severe soft-tissue damage. The use of a preformed antibiotic spacer allows maintaining joint function at the intermediate stage in two-stage treatment.

Arthroscopic anterior capsular release for idiopathic frozen shoulder

IntroductionFrozen shoulder (Adhesive capsulitis) has been defined as a condition characterized by both active and passive loss of motion. Zuckerman et al further classified Frozen shoulder into primary and secondary groups. Primary or idiopathic frozen shoulder has by definition no clear cause. The initial treatment consists of conservative management with NSAID, Physiotherapy, intra-articular steroids or saline and in some instances manipulation under anaesthesia. Once in a while there are cases which are refractory to conservative treatment and manipulation under anaesthesia has its risks like fractures and rotator cuff tears. Arthroscopic capsular release of stiff shoulders has been done providing excellent functional outcome and reproducible results. AimThe purpose of this study was to prospectively evaluate the efficacy of arthroscopic anterior capsular release for patients with refractory idiopathic adhesive capsulitis. Methods26 patients (sixteen males, ten females) with a mean age of 58.4 years (range; 44-72 years) were followed up at our institution. Arthroscopic anterior capsular release was done using two portals. Synovectomy was done using a shaver and capsular release was done using radiofrequency ablator. ResultsThe functional outcome was evaluated using ASES (American Shoulder and Elbow Society) and Constant and Murley scoring system. At 12 months, mean improvement in ASES score was 38 points and Constant and Murley score was 40.5 points. Out of 26 patients 22 said that they would recommend the procedure to someone

Results of Arthroscopic Repair of Type II Superior Labral Anterior Posterior Lesions in Overhead Athletes

Background: The majority of the literature on surgical outcomes of superior labral anterior posterior (SLAP) repairs has focused on short-term follow-up of 1 to 2 years, not allowing adequate time for full rehabilitation and return to maximum level of competition for all types of athletes. Also, previous studies have concentrated on using questionnaires that primarily evaluate patients’ activities of daily living, which do not focus on sport-specific performance. Purpose: To determine the midterm results of type II SLAP repairs in overhead athletes, focusing primarily on athletic performance as well as activities of daily living. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of 30 overhead athletes, who underwent an arthroscopic superior labral repair for a symptomatic type II SLAP tear between 2002 and 2007, was performed. Our study population included 22 male and 8 female patients with a mean age at the time of surgery of 24 years. Twenty-one patients participated in baseball or softball, and the remainder of patients were involved in javelin throwing or tennis. The average follow-up was 3.5 years. The outcome of treatment was evaluated using the American Shoulder and Elbow Society (ASES) scoring system, assessing activities of daily living, and the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, assessing sport-specific performance. In addition, the length of time to return to sport and the degree of successful performance were evaluated. Results: Repairs resulted in ASES scores comparable with those from prior published studies (average ASES score, 87.9). The KJOC score averaged 73.6. The athletes’ perception was that they returned to approximately 84.1% of their preinjury level of function with a mean time to return to play of 11.7 months. There was a significant drop in the ASES to KJOC score for the baseball/softball players (87.9 ± 14.94 and 72 ± 19.24, respectively; P = .006). Patients reported an overall satisfaction rate of 93.3% with the procedure, with the majority being very satisfied. Conclusion: Arthroscopic SLAP repairs show excellent results and a high rate of overall satisfaction; however, the outcomes are less reliable in throwers. The KJOC score provides a more stringent assessment of overhead athletes’ function after SLAP repair than the ASES score. Our findings also indicate that SLAP repairs lead to improved shoulder function during routine daily activities but that consistent return to elite throwing sports may still remain somewhat problematic.

Arthroscopic Bankart repair with suture anchors: results and risk factors of recurrence of instability

To evaluate retrospectively the results of arthroscopic Bankart repair using suture anchors for recurrent anterior shoulder dislocation with a minimum 1-year follow-up and to assess risk factors for recurrence. From March 2002 to March 2010, 259 patients with recurrent anterior shoulder dislocation underwent arthroscopic Bankart repair with suture anchors. And 188 patients (50 athletes, 138 nonathletes) were available for follow-up. The mean age at the time of surgery was 25.3 years (range, 13 - 58 years). The mean follow-up was 38.6 months (range, 12 - 110 months). All of the 188 patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Society (ASES) shoulder score and Rowe score system. The rate of recurrent instability, range of motion, and risk factors for postoperative recurrence were evaluated. The ASES score was 72.6 preoperatively, and Rowe score was 33.4. The ASES scores improved significantly to 91.9 postoperatively (P < 0.001). The Rowe scores improved to 81.9 postoperatively (P < 0.001). And 152 patients were greatly satisfied with the results, 16 satisfied and 20 unsatisfied. The satisfactory rate was 89.4%. 24 patients (12.8%) suffered a recurrence after surgery, 14 athletes and 10 nonathletes. The recurrence rates were 28.0% in the athlete group and 7.2% in the nonathlete group. On average there was no significant loss of external rotation postoperatively (average, 75.2° preoperatively and 67.2° postoperatively). Patients under age 20, and athlete patients were associated with recurrence (P < 0.05). Other factors including length of time until surgery, type of anchors, number of anchors, presence of bony Bankart lesion, presence of a superior labrum, anterior and posterior tear, presence of posterior or inferior labrum lesion, presence of rotator cuff tear, ligamentous laxity and rotator interval closure did not influence the recurrence rate (P > 0.05). Arthroscopic Bankart repair is a good option for the treatment of recurrent anterior shoulder dislocation. Identification of risk factors for recurrence allows for consideration of open stabilization. In the series, patients under age 20 and athlete patients are the most important risk factors for recurrence.

Clinical results after all arthroscopic reduction and fixation of bony Bankart lesion

To investigate the shoulder function after arthroscopic reduction and internal fixation in patients with bony Bankart lesion. Between May 2004 and May 2008, 45 patients with bony Bankart lesion who were treated with all arthroscopic reduction and internal fixation with metal anchors were included in this study. Among them 40 patients were male and 5 patients were female. The average age at the surgery was 27.6 years (16.5 - 50.1 years). The average duration of follow-up was 29.7 months (24.8 - 49.0 months). A history of recurrent dislocation of affected shoulder was found in all patients. Metal anchors were used to fix the bony Bankart lesion during the surgery. Hill-Sachs remplissage technique was used to treat the Engaging Hill-Sachs lesion. The preoperative American Shoulder and Elbow Society (ASES) score, Constant-Murley score, Rowe score and the VAS score for instability were 84 ± 14, 95.1 ± 4.6, 39.4 ± 2.9 and 5 ± 3 respectively. No significant change was found regarding active forward elevation, external rotation and internal rotation after the surgery. The ASES score, Constant-Murley score, Rowe score and the VAS score of stability were 95 ± 7, 98.3 ± 2.2, 84.5 ± 22.0 and 1 ± 2, improved significantly higher after the surgery (P < 0.01). One subluxation and 3 redislocation were happened during follow-up. The overall failure rate was 8.9% (4/45). All arthroscopic reduction and fixation of bony Bankart lesion can achieve a good result.