And Elbow Surgeons Shoulder Score Research Articles

Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved.

Management of massive rotator cuff tears (MRCTs) remains debated, and various arthroscopic and open techniques have been described for their management. Nevertheless, the optimal strategy remains unclear. The present study evaluated the clinical results in patients managed arthroscopically for MRCTs augmented with the long head biceps tendon (LHBT) at a minimum 1-year follow-up, considering different type of tears, demographic data and number of torn tendons. Patients treated in a secondary referral centre from January 2021 to April 2022 were enroled prospectively. Inclusion criteria were pain, inability to fully elevate the affected shoulder, irreparable tears and active and motivated patients. All patients were managed within 2 months from diagnosis in a single centre by the same surgeons. Preoperative shoulder radiographs and magnetic resonance imaging (MRI) were collected, and clinical assessment was also performed using the Numerical analogue scale (NAS), Constant score (CS) American Shoulder and Elbow Surgeons Shoulder Score (ASES). Tissue retraction and tendon fatty infiltration were evaluated using Patte and Fuchs scale, respectively. Clinical assessment was performed using the same scales at 3-6 months and 1-year follow-up. A total of 55 patients (31 female and 24 male) with a mean age of 60 ± 7.1 years were enroled for a mean follow-up of 18.2 ± 4.3 months. The mean preoperative NAS was 7.8 ± 0.6, CS was 20.5 ± 7.6 and ASES was 22.6 ± 9.2, increasing, respectively, to 0.3 ± 0.6, 91.5 ± 6.9 and 94.2 ± 6.7. No adverse side effects (infection, rejection, allergy) were reported during the study period. All patients were evaluated after surgery at 3 and 6 months and 1 year with statistically significant improvement for each score at the first and last follow-up (p < 0.05). The use of LHBT augmentation in patients with MRCTs in appropriately selected patients is safe and effective and can lead to pain relief and acceptable clinical outcomes. Furthermore, its use carries low donor site morbidityand is cost effective. Comparative studies, including randomised controlled trials, with other proposed techniques are needed to confirm these findings. Level IV.

Understanding overall shoulder function and health: the value of specific quantitative vs. qualitative shoulder range of motion on patient-reported outcome measures

Hypothesis and BackgroundIt is known that, though widely used, shoulder range of motion (ROM) measurements are not standardized and have a high rate of intra- and interobserver differences. Particularly, the inconsistency in quantitative and qualitative measurements and their relationship to patient-reported outcome measures (PROMs) make shoulder health difficult to determine. MethodsThis was a prospective study of 147 patients who presented with a chief complaint of shoulder pain to the orthopedic sports medicine and shoulder clinic of a single fellowship-trained surgeon. Measured by one examiner, quantitative ROM measurements were taken with a goniometer and qualitative ROM measured by the anatomic level that the patient could reach. The following PROMs were used as well: American Shoulder and Elbow Surgeons Shoulder Score (ASES), Single Assessment Numeric Evaluation (SANE), Shoulder Pain and Disability Index (SPADI), Oxford Shoulder Score (OSS), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), 12-Item Short Form Health Survey (SF-12), and Patient-Reported Outcomes Measurement Information System pain interference short form 6a (PROMIS 6a). Statistical analysis was performed with SPSS using Pearson correlation and two-sample t-test. Benjamini-Hochberg correction was used to determine p-value at which statistical significance was reached to correct for multiple comparisons. ResultsQualitative internal rotation (IR), (the hand behind back reach test) and qualitative forward flexion (FF) correlated with all goniometer angle measurements and PROMs (both shoulder and general health scores). These qualitative measures proved to be an appropriate proxy for IR and FF goniometer measurements. Qualitative external rotation (ER) was not a good substitute for quantitative ER measurement. Quantitative ER correlated with all PROMs. As ROM increased when measured by quantitative ER, qualitative IR, and qualitative FF, shoulder and general health PROMs incrementally increased as well. Discussion/ConclusionQualitative IR measurement, the hand-behind-back reach test, is an adequate substitution for IR goniometer angle as well as a strong representation of global shoulder ROM, shoulder health, and general health while factoring in patient age. Qualitative FF measurement is also an appropriate proxy for quantitative FF and represents global shoulder and general health without factoring in age. Quantitative ER via goniometer angle, is a better assessment of the shoulder than qualitative ER and is a representation of overall shoulder and general health. We recommend the use of quantitative ER, qualitative IR, and qualitative FF measurements to best understand a patient’s overall shoulder health and its impact on their overall health.

Outcomes of revision versus re-revision reverse total shoulder arthroplasty: A case–control-matched cohort study

Background The increasing incidence of reverse total shoulder arthroplasties (RTSA) has led to an increase in revision surgery. We aimed to compare patients undergoing re-revision RTSA to a matched cohort undergoing first-revision RTSA. Methods A retrospective review of all revision RTSAs was performed at a single institution. Sixteen shoulders that underwent re-revision RTSA were matched 1:3 to shoulders that underwent revision RTSA with a minimum two-year follow-up. Outcome scores including the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Short-Form 12 (SF-12), Shoulder Pain and Disability Index (SPADI), and Simple Shoulder Test (SST) scores, range of motion (ROM), and improvement from preoperative to postoperative outcomes after re-revision RTSA were assessed. Additionally, postoperative outcomes after re-revision RTSA were compared to patients that underwent first revision RTSA and subsequently compared to the minimal clinically important difference (MCID) values for the outcome scores and ROM measurements assessed. Results Sixteen shoulders that underwent re-revision RTSA and 78 revision RTSAs met the final inclusion criteria to be included in this study. Significant improvement from preoperative to postoperative re-revision RTSA was seen in the ASES score (p = 0.046), SPADI score (p = 0.044), SST (p = 0.008), abduction (p = 0.016), and elevation (p = 0.025), but not the SF-12 score (p = 0.396), external rotation (p = 0.449), or internal rotation (p = 0.451). Outcomes after revision RTSA were found to be superior to outcomes after re-revision RTSA for all outcome scores (ASES p = 0.029, SF-12 p = 0.018, SPADI p = 0.003) except the SST score (p = 0.080) and all ROM measures (p &gt; 0.05 for all). Internal rotation was equivalent postoperatively between both groups. From preoperative to postoperative re-revision RTSA, the mean improvement exceeded the MCID for the SST score, abduction, forward elevation, and external rotation. When comparing postoperative revision RTSA to postoperative re-revision RTSA, the mean difference between revision and re-revision RTSA exceeded the MCID for the SPADI score and external rotation. The complication rate was 19% in shoulders undergoing first revision and 41% in shoulders undergoing re-revision RTSA. Conclusion Patients undergoing re-revision RTSA receive improvement in clinical outcomes, but do not achieve outcomes comparable to those achieved after first revision RTSA.

Poster 197: Thresholds for Preoperative Opioid Use in Arthroscopic Rotator Cuff Repair that Negatively Influence Postoperative Clinical Outcomes

Objectives: The objective of this study was to evaluate preoperative opioid use along a spectrum to better understand the role that preoperative opioid use has on postoperative outcomes. Methods: A consecutive series of patients undergoing arthroscopic RCR from 2018 to 2020 were included. Preoperative opioid use within one year of surgery was determined using the state prescription drug monitoring program (PDMP). Cumulative morphine milligram equivalents (MME) from prescriptions one year prior to surgery and the number of days the last opioid was prescribed before surgery determined. Postoperative outcomes at 3 and 6 months included visual analog scale (VAS) for pain and American Shoulder and Elbow Surgeons Shoulder Score (ASES). The proportion of patients achieving patient acceptable symptom state (PASS) for VAS and ASES were determined. Multivariate generalized estimating equations models were utilized to determine the influence of preoperative opioid use on postoperative outcome scores with receiver operator characteristic (ROC) analysis. Results: 763 patients (47.6% male) with a mean age of 60.2 + 10.0 years were included. 488 patients (64%) had no history of opioid use one year prior to RCR, while 275 (36%) had an opioid prescription one year before RCR. Compared to patients without preoperative opioid use, patients with preoperative opioid use had an average ASES value 7.9 points lower (p&lt;0.001), and average VAS value 1.0 points greater (p&lt; 0.001). PASS for VAS and ASES at 6 months was achieved in 28% and 56% of patients prescribed preoperative opioids compared to 46% and 59% without. There was no association between the number of days from opioid prescription to surgery for ASES score (p=0.23) nor VAS score (p = 0.37). ROC analysis with MME categories of 0-200, 200-500, and &gt;500 MME yielded an area under the curve of 0.74 for PASS ASES and 0.78 for PASS VAS. Compared to patients with preoperative prescription &lt;200 MME, patients prescribed &gt;500 were 35.7% (p=0.03) less likely to achieve ASES PASS. For every 100 preoperative MME prescribed, ASES score decreased by 0.11 (p=0.001) while VAS increased 0.018 points (p&lt;0.001). For every 100 preoperative MME prescribed, the probability of achieving PASS for VAS decreased by 1.8% (p=0.004). Conclusions: Preoperative opioid use is a risk factor for diminished clinical outcome scores and higher pain following RCR in the early postoperative setting. The risk profile is modified by total preoperative opioid prescription MME as higher preoperative opioid use is associated with lower ASES, higher VAS, and lower likelihood of achieving PASS for VAS and ASES. Preoperative opioid prescription threshold values of 200 and 500 MME negatively worsened clinical outcomes to greater degrees. Patients with increasing preoperative opioid use should be counseled that lower clinical outcomes and higher pain levels may occur following RCR.

Effects of Platelet-Rich Plasma in Tear Size Reduction in Partial-Thickness Tear of the Supraspinatus Tendon Compared to Corticosteroids Injection

ObjectivesCorticosteroid (CS) injection is commonly used in partial-thickness rotator cuff tears to decrease pain. However, this could result in unwanted side effects, such as tendon rupture. Alternatively, platelet-rich plasma (PRP) injection is frequently used to treat tendinopathies because it enhances healing. This study aimed to compare the differences in tear size and functional scores between intralesional PRP and subacromial CS injections.MethodsPatients with symptomatic partial-thickness tears of the supraspinatus tendon who underwent conservative treatment for ≥ 3 months were enrolled. All patients underwent magnetic resonance imaging (MRI) to confirm the diagnosis. Fourteen and 15 patients were randomized to receive intralesional PRP and subacromial CS injections, respectively. Tears were measured in the coronal and sagittal planes. The patients underwent another MRI 6 months after the injection. Tear size was compared between the two MRI results. The American Shoulder and Elbow Surgeons Shoulder score (ASES) and Constant–Murley score (CMS) were also obtained.ResultsThe baseline data were similar between the groups. In the coronal plane, PRP and CS showed tear size reductions of 3.39 mm (P = 0.003) and 1.10 mm (P = 0.18), respectively. In the sagittal plane, PRP and CS showed tear size reductions of 2.97 mm (P = 0.001) and 0.76 mm (P = 0.29), respectively. Functional scores improved 6 months after injection in both groups, but PRP showed better functional scores than CS (P = 0.002 for ASES, P = 0.02 for CS).ConclusionIntralesional PRP injection can reduce the tear size in partial-thickness tears of the supraspinatus tendon. Subacromial steroid injection did not significantly affect the tear size. While CS improved functional scores compared with baseline, PRP resulted in better improvement 6 months post-injection.Trial registration Thai Clinical Trials Registry, TCTR20210428004. Registered 28 April 2021-retrospectively registered, TCTR20210428004.

Short-term Clinical Outcome of Dual Plate Fixation in the Treatment of Proximal Humerus Fractures with Calcar Comminution.

Calcar comminution has been considered to be the main cause of the failure of internal fixation and fracture nonunion in proximal humerus surgery. Anatomical reduction and increasing the strength of internal fixation is the key to success. The purpose of this study was to investigate the short-term clinical effect of dual plate fixation in the treatment of proximal humeral fractures with calcar comminution. The data of 37 patients with proximal humeral fractures with calcar comminution, treated in our departments from July 2018 to April 2020, were retrospectively analyzed. These patients were treated with anterior plate and lateral PHILOS plate, and followed up for more than 12 months, including 25 cases in Tianjin Hospital and 12 cases in Shanghai General Hospital. The patients included 12 males and 25 females, their age was 54.89 ± 13.59 years (range from 32-79 years), and 21 patients had dominant hand injury. According to the Neer classification, there were 11 two-part fractures, 22 three-part fractures, and four four-part fractures. The range of motion of the shoulder joint, visual analog scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant-Murley shoulder score, neck-shaft angle, anterior-posterior angle, and other complication scores were recorded at the last follow-up. All 37 patients were followed up after operation, and the follow-up time was 21.81 ± 7.35 months (range from 12-36 months). The fractures of all 37 patients had healed at the last follow-up visit. The neck-shaft angle measured immediately after operation was 132.59° ± 8.34°, and the neck-shaft angle measured at the last follow-up visit was 132.38 ± 8.53°. The anterior-posterior angle measured immediately after surgery was 3.45° ± 0.81°, and the anterior-posterior angle at the last follow-up visit was 3.66° ± 0.77°. The range of motion of the shoulder joint was as follows: the shoulder joint could be forward elevated by 158.11° ± 13.09° (range: 140°-180°), rotated externally by 38.38° ± 7.55° (range: 20°-45°), and internally rotated to T4-L4 level. The VAS score was 0.46 ± 0.87 (range: 0-3), the ASES was 86.58 ± 8.79 (range: 56.7-100), and the Constant-Murley score was 88.76 ± 8.25 (range: 60-100). Thirty-three cases were excellent, and four cases were good. No obvious complications occurred. The combination of anterior plate and lateral PHILOS plate in the treatment of proximal humeral fractures with calcar comminution can achieve stable fixation, and the postoperative clinical and imaging outcome was satisfactory. Firstly, the anterior plate can provide temporary stability when the Kirschner wires are removed, which can provide space for lateral plate placement during fracture reduction and fixation. Secondly, additional support by the anterior plate can provide higher stability in complex fractures with calcar comminution.

Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes

The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management. A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS). Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P= .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores. Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair. Retrospective comparative study; Level of evidence,3.

Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes.

To compare failure rates and outcomes after transosseous equivalent (TOE) double row (DR) knotted suture bridge versus knotless suture tape bridge repair techniques for rotator cuff tears. A consecutive series of 272 shoulders in 256 patients who underwent arthroscopic, double row, TOE repair for full-thickness tears of the supraspinatus tendon were reviewed. Eighty-four shoulders were repaired using knotted suture bridge (KSB) technique, and 188 shoulders were repaired using all knotless suture tape bridge (KTB) technique. Revision procedures and concomitant subscapularis tendon repairs were excluded from analysis. The minimum follow-up was 12months. Primary outcome was failure of surgical repair, defined as either confirmed retear on MRI and/or need for revision surgery. Secondary clinical outcome measures were assessed including range of motion, strength, visual analog scale (VAS), operative time, subjective shoulder value (SSV), Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Brophy shoulder activity scores, and need for manipulation under anesthesia (MUA). A total of 127 shoulders (38 KSB and 89 KTB) met inclusion criteria for the study. No significant difference in demographic variables were present between the groups at baseline. Supraspinatus tear size and average follow-up time did not differ significantly between groups. Failure rates were similar between the KSB and KTB repairs (13.1 vs 7.9%, n.s.). There was no significant difference in functional outcomes including strength, range of motion in forward flexion and external rotation, as well as patient reported outcomes including VAS, SSV, PROMIS, ASES, and Brophy scores between the groups. There was also no difference in post-operative stiffness requiring MUA. Both KSB and KTB repair techniques demonstrate low retear rates with excellent functional outcomes when compared to pre-operative examination. Both KSB and KTB techniques are viable options for achieving a successful rotator cuff repair. Level III.

Poster 140: Shoulder Strengthening and Stabilization Systems – A Viable Option for Early Passive Range of Motion after Arthroscopic Rotator Cuff Repair

Objectives:Post-operative rehabilitation following arthroscopic rotator cuff repair (ARCR) is crucial for optimal outcomes. Early post-operative passive range of motion (PROM) is encouraged by some surgeons to minimize the development of adhesions and subsequent decreased range of motion. Existing literature comparing early and delayed PROM for small and medium size tears has demonstrated equivalent functional outcomes, with early PROM resulting in improved long-term active range of motion (AROM). The specific modality used for early PROM varies and may include manual home exercises, machine-assisted home exercises, or formal physical therapy (PT). In this study, we investigated Shoulder Strengthening and Stabilization Systems (SSS) (Advanced Integrated Motion; Elizur), a home-based machine monitored through telemedicine which allows for passive, active-assisted, and active motion in the early post-operative rehabilitation process. The benefit of SSS predominantly derives from the convenience of performing early PROM at home instead of attending in-person formal physical therapy. The objective of this study was to compare patient reported outcomes (PROs) and perioperative AROM after ARCR between patients who utilized SSS and those who underwent formal PT. We hypothesized that those who use SSS would have equivalent ROM and PROs compared to those who did not use SSS.Methods:A retrospective study comprised of patients undergoing RCR between 2018-2020 was conducted. Cohorts were defined by confirmation of SSS utilization via data provided by Elizur. SSS was started within several days following surgery in lieu of formal PT which started at 6 weeks. This was matched with a control group undergoing ARCR over the same time range, who initiated a formal PT protocol without the SSS machine when it was not available at our institution. The post-operative rehabilitation protocol consisted of PROM/pendulums beginning at 10 days, AROM at 6 weeks, and strengthening at 12 weeks. Data were collected from electronic medical records (EMR), entered into an institutional redcap database (UL1-TR-001857), and institutional review board approval was acquired. Patients undergoing concomitant labral repairs, capsular reconstruction procedures, revision ARCR, or with less than 3 months follow up were excluded. Primary outcome measure was subjective shoulder value (SSV) score. Secondary outcomes included American Shoulder and Elbow Surgeons Shoulder Score (ASES), visual analog scale (VAS), and AROM (forward flexion and external rotation). Baseline characteristics were analyzed with two sample t-tests and chi-square or Fisher’s exact test for continuous and categorical variables, respectively. A linear mixed model with fixed effects for cohort, time, and the cohort-time interaction was used to analyze PROs and AROM at various timepoints. Statistical significance was set at p < 0.05.Results:A total of 417 patients (243 SSS; 174 no SSS) with an average follow up of 5.5 months met inclusion criteria. SSS was used for an average of 36.2 days. Baseline characteristics including gender, BMI, nature of injury, time from injury to surgery, and preoperative PROs (SSV, ASES, and VAS) did not differ significantly between cohorts. The cohort without SSS was older at the time of surgery (61.3 years vs. 59.3 years, p=0.03). Linear mixed model analysis revealed no significant differences in AROM at any timepoint (table 1). There was no significant difference between cohorts with respect to SSV, ASES, and VAS at any timepoint (Table 2). Both cohorts had significant increases in each PRO over time, exceeding minimal clinically important difference (MCID) at 6 months post-operatively.Conclusions:The use of SSS demonstrated excellent ROM and patient reported outcomes equivalent to those who initiated formal PT in the early postoperative period. The convenience of a home-based therapy program monitored via telemedicine in lieu of formal PT during the first 6 post-operative weeks may be an attractive option for patients following ARCR. Future studies will elucidate whether there are potential cost saving implications.Table 1.Active Range of Motion Over TimeTable 2.Patient Reported Outcomes Over Time

Poster 152: Arthroscopic Bankart Repair Following a Second Dislocation Results in Increased Failure Rates Compared to Immediate Repair After Following a Traumatic First Time Dislocation

Objectives:Many surgeons will consider nonoperative treatment following a 1st time dislocation and will consider operative management if a second instability event occurs particularly for the in season athlete. The objective of this study was to compare rates of recurrent dislocation and post-surgical outcomes in patients undergoing arthroscopic bankart repair for anterior shoulder instability immediately following a 1st time traumatic anterior dislocation versus patients who sustained a 2nd dislocation event following initial conservative management. We hypothesized that patients sustaining a 2nd anterior shoulder dislocation would be more at risk for recurrent dislocations after arthroscopic repair and secondarily, would have worse objective and subjective outcomes.Methods:This was a retrospective chart review identifying all patients undergoing primary arthroscopic surgical stabilization for anterior shoulder instability between 2013-2019 at a single academic institution. Demographics, clinical history, physical exam, imaging, operative details, and postoperative course was reviewed. Patients were eligible for inclusion if they underwent arthroscopic Bankart repair without remplissage sustained one or two dislocation events and were clinically followed for a minimum of 12 months postoperatively. Exclusion criteria included posterior instability, multidirectional instability, and previous stabilization surgery, Primary outcome was documentation of recurrent shoulder dislocation during the postoperative period. Secondary clinical outcome measures were assessed including need for revision surgery, need for manipulation under anesthesia (MUA), range of motion, strength, Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), PROMIS mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Brophy shoulder activity scores.Results:A series of 89 patients (mean age 21.3 years ± 7.3 years) met criteria for inclusion. 72 shoulders underwent surgical stabilization after a single shoulder dislocation event and 17 underwent surgery after sustaining two documented shoulder dislocations. No significant difference in demographic and radiographic characteristics, including presence of bony Bankart and off-track Hill Sachs lesions, was present between the groups. The rate of recurrent dislocation was significantly higher in the multiple dislocation group compared to single dislocations (31% vs 12%, p=0.048). There was a trend toward increased rate of revision stabilization in the 2nd dislocation group which did not reach statistical significance (22% vs 58%, p=0.167). No significant difference was present in the need for revision surgery, need for MUA, conversion to Latarjet procedure, range of motion, supraspinatus strength, VAS, PROMIS, ASES, and Brophy scores between the groups.Conclusions:Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and undergo surgical stabilization following just one additional event are at increased risk of failure following surgery. Furthermore, patients who have sustained even one additional dislocation from the primary event may benefit from more aggressive approaches may be necessary including arthroscopic approaches with augmentation or open approaches. Despite differences in recurrence rates, both groups achieved excellent subjective functional outcomes at a minimum of 12 months after surgery.

Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears: Technique and Associated Considerations

Background: Massive rotator cuff tears lead to superior humeral head translation and may prevent successful repair. Superior capsular reconstruction (SCR) can overcome this by improving the compression and depressor effects of the rotator cuff and joint capsule simultaneously. Indications: SCR is indicated in young, active patients with massive rotator cuff tears or a functional cuff deficiency from a failed previous rotator cuff repair without significant arthritis, articulation of the humeral head with the acromion, or dysfunctional deltoid. Technique Description: During the procedure, repair of the subscapularis is performed using a polydioxanone (PDS) suture shuttling device to pass suture through the subscapularis in an inverted mattress knotless configuration. Posterior infraspinatus tendon fibers are reduced and the tuberosity is abraded and decorticated followed by completion of the partial repair of the posterior cuff. Anchors are placed on the glenoid and articular margins followed by preparation of the dermal allograft with luggage tags medially and perforation laterally. The graft is passed and secured in a double row configuration laterally with apposition of the graft to the remnant, repaired rotator cuff posteriorly. Results: Passive range of motion (ROM) is begun at week 4, followed by progressive active ROM at weeks 6 to 12, and advancement of full ROM and advanced strengthening begun at 3 months. With SCR, a patient can expect maximal strength and function to be regained at 1 year postoperatively. Significant clinical improvement following SCR has been seen in visual analog scale (VAS) and American Shoulder and Elbow Surgeons Shoulder Score (ASES) scores for most patients, although there is a varied degree of return to sport following this procedure. Discussion/Conclusion: Clinical evidence suggests that SCR is a beneficial therapeutic intervention for short to medium term outcomes in younger patients with massive, irreparable rotator cuff tears. More studies are needed to identify the optimal thickness of the graft.

The effect of arthroscopic rotator cuff repair on sleep in degenerative full-thickness tears.

Shoulder pathologies are frequently linked to sleep disturbances. The aim of this study is to investigate the effect on sleep disorders in patients with arthroscopic rotator cuff repair. Thirty-three patients who underwent arthroscopic rotator cuff repair due to a full-thickness rotator cuff tear were prospectively analyzed. The Pittsburgh Sleep Quality Index (PSQI), the American Shoulder and Elbow Surgeons Shoulder Score (ASES), visual analog scale (VAS), and Constant and Murley shoulder scores before surgery and at 6 months postoperatively. Preoperative clinical and radiological parameters of the patients were also evaluated. The study analyzed 33 patients with a median age of 59.79 ± 9.0 years. There was a significant difference preoperatively versus postoperatively in terms of all PSQI global scores and subdivisions (P < 0.001). A statistically significant improvement was determined by the simple shoulder test, the Constant and Murley shoulder scores, and VAS (P < 0.001). Sleep disturbance is common in patients with symptomatic rotator cuff tear, and sleep disturbance can resolve after arthroscopic rotator cuff repair.

Functional outcome of surgical management of proximal humerus fracture treated by various modalities

Introduction: Fractures of the proximal humerus constitutes 7% of all fractures and approximately one-half of all humerus fractures. In the elderly population above 65 years of age, these are second most frequent upper extremity fracture and third most common non vertebral osteoporotic fractures. Management of proximal humerus fracture with various treatment modalities has always been a topic of debate and draws much controversy and confusion with it because of the complexity of these injuries with fracture displacements. Moreover, even good anatomical results achieved with operative fixation may lead to poor results unless supported by a meticulous postoperative rehabilitation. Aim: To assess and compare the functional outcome with different modalities of the fixations in proximal humerus fractures. Method: a prospective study comprising of 23 patients with proximal humerus fractures classified through Neer’s classification. Modalities of treatment employed included (1) Closed reduction and Percutaneous K-wire fixation (2) Open reduction and Internal fixation with Locking Compression Plate (PHILOS) (3) Closed reduction and Internal fixation with Intramedullary Nail and (4) Shoulder Hemiarthroplasty. Functional outcome was evaluated using Constant Murley score and American Shoulder and Elbow Surgeons Shoulder Score (ASES) based on pain, function, strength and range of motion. Result: Higher incidence of these fracture was seen in (61%) females as compared to males. Most of the fractures (43%) occurred in the age group 50-60 years. Fall from a standing height was the most common mode of trauma in elderly patients while in younger patients, these fractures were mostly a result of RTA or sporting injuries. Two part and three part fractures were found to be commoner of all fractures constituting 39% and 34.8% respectively. Functional outcome evaluated using Constant Murley Score shown Excellent outcome in 13% cases, Good outcome in 34.8% cases and Fair outcome in 39.1% cases while in 13% patients, outcome was poor. The unsatisfactory results in our series was seen mostly in elderly patients who were reluctant or not compatible for rigorous rehabilitation program. Conclusion: Fractures of the proximal humerus have varied patterns and are complex injuries to manage. Reconstruction of the articular surface with restoration of the anatomy, achieving stable fixation, with minimal soft tissues damage and preservation of blood supply remains the key for attainment of optimal functional outcome.

Arthroscopic Rotator Cuff Repair Improves Sleep Disturbance and Quality of Life: A Prospective Study.

Sleep disturbances are very common in patients with rotator cuff injury. Improvement of sleep quality in these patients can be considered a significant factor for healing in conjunction with surgery. The primary objective of this prospective study was to evaluate changes in sleep quality after surgery in patients with rotator cuff repair by analyzing the PSQI (Pittsburgh Sleep Quality Index) score. The secondary aim was to evaluate the improvement in quality of life in terms of functional limitations and shoulder pain after surgery. Fifty-eight patients with rotator cuff tears treated by arthroscopic surgery were included. All the patients completed the PSQI, the 36-Item Short Form Survey (SF-36), the Simple Shoulder Test (SST), the American Shoulder and Elbow Surgeons Shoulder Score (ASES), the Oxford Shoulder Score (OSS) and the Constant-Murley Score (Constant) before and at one, three and six months after surgery. Overall improvement in all the scores analyzed (p < 0.001) was found. Preoperative and postoperative PSQI scores correlated with SF-36, SST, ASES and Constant scores at each follow-up. Preoperative and one-month postoperative OSS correlated with the PSQI score. Using the Friedman test, we found an overall improvement in all score analyses (p < 0.001). The results prove that after rotator cuff repair, sleep disturbances improve three to six months after surgery improving the quality of life of these patients.

CORR Insights®: What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors?

CORR Insights®: What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors?

Inlay hemiarthroplasty of the humeral head for nontraumatic osteonecrosis

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

Comparisons of complications between extended latissimus dorsi flap and latissimus dorsi flap in total breast reconstruction: A prospective cohort study

BackgroundThe latissimus dorsi (LD) flap is one of the most popular techniques in breast reconstruction. Although numerous studies have not shown functional impairment of the shoulder after surgery, other studies have reported significant functional impairment, especially after extended LD flap reconstruction. The present study compared functional deficit and shoulder movement between extended LD and LD flap reconstruction. Materials and methodsBetween December 2015 and May 2018, this study enrolled 31 patients undergoing LD flap reconstruction. Data on patient demographics, operative details, morbidities, and degree of shoulder movement were collected. Outcomes were compared between the extended LD and LD flap groups. ResultsTwenty-one women and 10 women underwent LD flap and extended LD flap reconstruction, respectively. The median patient age was 43 years. No demographic data differed between groups. Seroma, especially around the back incision, was the most common complication (90.5% in the LD flap and 90% in the extended LD group). Five patients in the LD flap group and one patient in the extended LD flap group showed decreased shoulder range of motion (ROM) at 6 months post-operation. Only one patient in the LD flap group showed impairment based on American Shoulder and Elbow Surgeons Shoulder Score (ASES). The results did not differ significantly between groups; however, the LD flap group showed faster functional recovery. ConclusionLD flap reconstruction can be performed with a very low impact on shoulder function. We observed a slightly decreased ROM for both LD flap techniques, with no impact on functional outcome.

All arthroscopic coracoclavicular button fixation is efficient for Neer type II distal clavicle fractures.

Neer type II distal clavicle fractures are associated with a high rate of non-union or malunion due to impaired coracoclavicular ligament stability. The purpose of this study was to assess the clinical and radiological outcomes of arthroscopically assisted indirect osteosynthesis for type II distal clavicle fractures using a cortical suture button device. Seventeen patients Neer type II fractures of the distal clavicle were treated surgically using cortical suture button fixation between 2012 and 2017. The clinical and radiological results were assessed using the American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant-Murley score and visual analogue scale (VAS) score. Anatomic reduction and bone healing were achieved in all patients at the final follow-up. The median age of the patients was 31years (range 19-57). The mean follow-up was 25.9months (range 14-64). The average delay before surgery was 2days (range 1-4). At the final follow-up, the mean ASES, Constant-Murley score and VAS score were 92.6 ± 3.2 (range 84.9-96.6), 96.2 ± 2.4 (range 92-100) and 0.47 ± 0.51 (range 0-1), respectively. All patients were able to resume work as well as sport activities. The postoperative complications included two coracoid process fractures, and none of the patients required additional surgery related to the index procedure. All arthroscopic coracoclavicular button fixation of Neer type II distal clavicle fractures would provide sufficient stability and union with satisfactory radiological and clinical outcomes. This arthroscopic fixation technique would be more efficient than other osteosynthesis methods because it is a minimally invasive surgery with a low complication rate. III.

Arthroscopic partial repair with versus without biodegradable subacromial spacer for patients with massive rotator cuff tears: a case-control study.

To investigate whether arthroscopic partial repair with the additional use of a biodegradable subacromial spacer would be proven better treatmentfor irreparable massive rotator cuff tears (MRCT) compared to single arthroscopic partial repair. A matched-pairs case-control study of 32 patients suffering from irreparable MRCT who underwent an arthroscopic partial repair with (Group B: 16 patients) or without (Group A: 16 patients) InSpace Balloon (ISB®; Orthospace, Caesarea, Israel) implantation was conducted. For the clinical and functional assessment of the patients, the visual analog scale, Constant score, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Range of Motion (RoM), and patients' satisfaction were obtained. The two groups were matched in all baseline demographic and clinical characteristics (n.s.). All mean final quantitative postoperative clinical and functional scores of group A (partial repair and ISB) and group B (single partial repair), as well as active RoM, were significantly improved (t test) in comparison with the mean preoperative values (p < 0.05). No significant differences were observed between the two groups in relation to the two success rate criteria (ASES minimal clinically important difference or MCID > 17, Constant score MCID > 10.4), as well as pain relief and RoM 12months after surgery. Arthroscopic partial repair, either with or without ISB implantation, resulted in significantly improved clinical and functional short-term outcomes for the treatment of MRCT. Patients who were treated with combined partial repair and ISB implantation had a potential propensity toward better functional outcomes and higher patient satisfaction compared to the single-partial-repair-treated group. However, given that these differences were not significant, we feel that further studies are required to clarify the potential therapeutic value of ISB implantation in the treatment of irreparable MRCT. Level III. German Clinical Trials Register (WHO International Clinical Trials Registry Platform). ID number: DRKS00014725. Date of registration: 07/05/2018.

Treatment of unstable distal-third clavicule fractures using minimal invasive closed-loop double endobutton technique

BackgroundClavicle fractures are common clinical problems, accounting for approximately 10% of all fractures. Neer’s type II fractures disrupt the integrity of the coracoclavicular ligament and, therefore, are inherently unstable, requiring an extended period time to achieve bone union and being associated with a high rate of non- or malunion. Restoration of the stability of the distal clavicle is an important factor to decrease the rate of non- or malunion. As such, the aim of our study was to describe our technique of indirect osteosynthesis, using a minimally invasive closed-loop double endobutton (TightRope) technique for fixation of unstable (Neer’s type II) distal clavicle factures, and to evaluate the short-term clinical outcomes.MethodsFifteen patients with a Neer’s type II fracture of the distal clavicle were treated surgically using the TightRope fixation, between January 2016 and December 2017. Clinical and radiological results were assessed using the American Shoulder and Elbow Surgeons Shoulder Score (ASES) and the Constant score.ResultsDefinitive fracture healing was achieved in most of the patients. No major complication was identified over a mean follow-up of 9 months, and none of the patients required additional surgery related to the index procedure. At the last follow-up, all patients had recovered functional range of motion of the shoulder, with high Constant and ASES scores, and low pain score.ConclusionThe use of TightRope fixation provided sufficient stability to reduce the medially displaced fragment of the Neer’s type II fracture, with satisfactory radiological and clinical outcomes achieved over a mean follow-up of 9 months. Future studies on the long-term outcomes are needed.