ASES Score Research Articles

Poster 165: Psychosocial Factors Play a Greater Role in Preoperative Symptoms for Patients with Atraumatic Shoulder Instability: Data from the Moon-Shoulder Instability Group

Objectives:Previous studies have demonstrated altered brain activation patterns on functional MRI for those with shoulder instability suggesting a potential link between recurrent instability, depression, and emotional wellbeing. It is unknown whether this potential link would differ between those with traumatic vs. atraumatic instability. The purpose of this study was to determine whether psychosocial factors and/or comorbid depression play a greater role in preoperative symptoms for patients with atraumatic or traumatic mechanisms of shoulder instability. We hypothesized that when controlling age, sex, and direction of instability, psychosocial factors and comorbid depression would be more predictive of shoulder-related pain and symptoms for patients with atraumatic instability than patients with traumatic instability.Methods:As part of the IRB-approved Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, 1553 patients provided informed consent and completed pre- and intraoperative data collection. Patients were categorized based on self-reports of whether the mechanism of shoulder instability was traumatic (n=1267) or atraumatic (n=286). Multivariable linear regressions were performed to determine whether psychological factors (VR12, Mental Component Score (MCS), Depression Diagnosis, PAS-22) were predictive of preop ASES and WOSI score in the atraumatic group, controlling for age, sex, and the direction of instability. The same model was repeated for the traumatic instability group, and the model fit was compared between groups using the methods described by Cohen, Cohen, and West with p < 0.05 considered statistically significant.Results:Sex and Mental Component Scores (MCS) were significantly predictive of preop ASES and WOSI scores for the group with atraumatic instability (ASES r2=0.15, p<0.001; WOSI r2=0.17 p<0.001). The same model performed significantly worse for both ASES and WOSI scores in the group with traumatic instability (ASES r2=0.06, WOSI r2=0.07, p<0.05 for both ASES and WOSI).Conclusions:Preoperative psychosocial factors were found to be more predictive of shoulder-related pain and symptoms for patients with atraumatic instability. Across multiple orthopedic conditions, depression and emotional wellbeing have been associated with worse preoperative symptoms and inferior postoperative patient-reported outcomes. As opposed to medically optimizing patients prior to surgery, the current findings identify a subset of shoulder instability patients that may need to be psychologically optimized either prior to surgery or early in the postoperative period to potentially improve postoperative outcomes.

Paper 90: Histopathology of Rotator Cuff Tendons in Elderly Patients with Glenohumeral Arthritis without Cuff Tears

Paper 90: Histopathology of Rotator Cuff Tendons in Elderly Patients with Glenohumeral Arthritis without Cuff Tears

Poster 180: Diagnostic Algorithm and Outcomes of Treatment for Neurogenic Pectoralis Minor Syndrome

Objectives:Neurogenic pectoralis minor syndrome can generate chronic anterior shoulder pain and a variety of non – specific neurologic symptoms in an affected upper extremity. This study presents a diagnostic algorithm used to identify neurogenic pectoralis minor syndrome and reports short-term outcomes for a series of patients who underwent either open or arthroscopic, coracoid – based, pectoralis minor tenotomy to treat the condition.Methods:Following IRB approval, the senior investigator’s operative records were queried for pectoralis minor release performed between January 2012 and July 2021. Demographic, surgical, and outcomes data was extracted from each subject’s medical record. Only subjects with a minimum of 30-day follow-up were considered in data analysis. Generalized descriptive statistical analysis, along with ANOVAs and post-hoc t-tests were performed to compare outcomes of pectoralis minor release.Results:Twenty-one subjects were identified meeting enrollment criteria. Mean age at time of diagnosis was 44.3years (range 17-70 years). Subjects had undergone prior shoulder surgery in 16/21 (76.2%) of cases and 18 (85.7%) were Worker’s Compensation related injuries. All patients had undergone a minimum of 3 months of a structured physical therapy program preoperatively. All patients underwent a diagnostic, ultrasound – guided pectoralis minor block with temporary resolution of self – reported symptoms. Symptoms prior to treatment included anterior shoulder pain and neurologic symptoms in 20/21 (95.2%) cases, with a mean duration of 15.7 months (range 3-40 months). Pretreatment ASES score was mean 41.5 (range 13.3-73.3) with mean pain of 4.9/10 (range 1-9/10). At mean 6.8 months post-release, patients reported mean 9.5 point increase in ASES score versus index score (p<0.05) and 85.0% (17/20 with pre-operative neurologic symptoms) reported complete resolution or improvement of neurologic symptoms related to neurogenic pectoralis minor syndrome.Conclusions:Findings of insertional pectoralis minor tenderness to palpation with or without reproduction of neurologic symptoms, a positive diagnostic, ultrasound – guided pectoralis minor block and anterior shoulder pain can be useful findings to establish the difficult diagnosis of neurogenic pectoralis minor syndrome. In select patients either open or arthroscopic release of the pectoralis minor insertion on the medial aspect of the coracoid process can alleviate symptoms.

Poster 135: Minimum 2 year Clinical Outcomes after Latarjet for anterior shoulder instability: clinical and imaging factors that correlate with success or failure

Objectives:The open Latarjet procedure has been demonstrated to be reliable in achieving acceptable patient reported outcomes (PROs). However, clinical predictors of outcome, return to sport and complications/failures have been more variable. The purpose of this study is to report patient reported outcomes (PROs), clinical correlations, and predictors of failure in patients who have received an open Latarjet surgery.Methods:Patients who received an open Latarjet with by two fellowship–trained surgeons between August 2006 - November 2018 were included. Prospectively collected data was reviewed, and PROs included ASES, SF–12 PCS, SANE, QuickDASH, and satisfaction. Age, sex, sports participation, pain, primary vs. revision (prior failed arthroscopic/open Bankart) surgery, dislocation number, glenoid bone loss (GBL), glenoid track concept, and projected glenoid track were evaluated. Projected track was calculated using the axial diameter of the corcoid as part of the glenoid track concept. Postoperative ASES <70, recurrent dislocation, or revision instability surgery were considered failures.Results:126 shoulders (125 patients) met inclusion criteria with mean age of 28.1 years (range 15–57). 7/126 (5.5%) had revision surgery prior to final follow-up and were excluded from outcomes analyses. Mean follow-up 3.7 years (range 2–9.3 years) was attained in 86.6% (103/119) of patients. All PROs significantly improved from preoperative baseline (ASES: 69.7→90.2; SANE: 55.8→85.9; QuickDASH: 28.4→10.5). PROs did not differ with sex, sport participation type, dislocation with/without sports, primary/revision, and preoperative dislocation number. No correlations existed between PROs and age, GBL, or number of previous surgeries. On-track (50/105, 47.6%) and projected on-track (90/105, 85.7%) lesions correlated with better patient satisfaction, but not PROs. A total of 97% (86/89) returned to sport, with 74% (66/89) at the same/slightly below pre-injury level. Failures included 13/126 (10.3%) postoperative dislocations and 6/126 (4.7%) with ASES scores <70.Conclusions:The open Latarjet procedure lead to significant improvements in all PROs, and overall 97% of patients returned to sport. On-track and projected on-track measurements correlated with better patient satisfaction, but not improved PROs. No other factors were predictive of outcomes, nor clinically correlated with failure.

Outcomes of reverse shoulder arthroplasty following failed superior capsular reconstruction.

Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown. Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n=1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups. Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P=.001) and worker's compensation cases (P=.034) in the SCR group. The RCR cohort was older (P=.007) and had a greater incidence of mental health (P>.999) and somatic disorders (P=.698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2±23.3 and 20.4±14.9 months following RSA, respectively (P=.913). The time from index RCR or SCR to RSA were 94.4±22.2 and 89.2±5.3 months, respectively (P=.003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P=.879), abduction (P=.971), and external rotation (P=.968) following RSA. The RCR group had lower postoperative VAS pain (P=.009), higher SANE (P=.015), higher ASES (P=.008), and higher WOOS (P=.018) scores. The percentage achieving the MCID (P=.676) and SCB (P>.999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P=.005). There were no differences in postoperative complications (P=.698) or revision rates (P=.308) following RSA between cohorts. When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

Paper 74: Psychopathology and Volitional Instability: Who should we be operating on?

Objectives:There has been a hesitation by surgeons to operate on shoulder instability patients with maladaptive psychopathological traits, especially those with volitional instability, as these may portend a poor prognosis. The purpose of this study was to investigate the prevalence of maladaptive psychopathological traits, volitional instability, and their effect on two-year outcomes in patients undergoing shoulder stabilization surgery.Methods:A prospective multi-center cohort study led by the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group targeted all subjects having surgical shoulder stabilization and collected patient-reported outcomes at baseline and at two years postoperatively. Psychopathological traits were assessed using the Personality Assessment Screener (PAS), a validated personality assessment tool. Longitudinal analyses were performed using multivariable regression models to determine predictors of two-year outcomes adjusting for confounders measured at index such as age, sex, smoking, BMI, volitional instability, and intraarticular pathology.Results:The cohort (n = 890) was 80% male with a median age of 21.5 years. The prevalence of psychopathological traits was 20%. While all patients improved between baseline and 2 years, with adjusted analyses, the presence of maladaptive psychological traits present at the time of index surgery were predictive of lower WOSI (p = 0.001), ASES (p = 0.016), SANE (p = 0.03), and SF-36 MCS (p = 0.001) scores as well as a higher risk of failure (p = 0.04) at two years. As a main effect, volitional instability was not a predictor of WOSI, ASES, SANE, SF-36 or failure at two years. However, all models allowed for the interaction between volitional instability and the PAS, and this interaction was significant for WOSI (p = 0.006), SANE (p = 0.03), and SF-36 MCS (p = 0.003) scores at two years. In other words, the effect of volitional instability on the WOSI, SANE, and SF-36 MCS scores depends on the value of the PAS, and with high PAS scores it is associated with worse outcomes. This data is depicted in Figures 1-3.Conclusions:While all patients improved, the presence of maladaptive psychopathological traits at the time of index surgery was a predictor of poorer outcomes at two years. Voluntary dislocators did similarly as non-voluntary dislocators up to a PAS score of ˜ 20, where above this they had worse WOSI, SANE, SF-36 MCS and higher failure rates at 2 years post-operatively.Figure 1.Adjusted effects of PAS score and volitional instability on WOSI score at 2 yearsFigure 2.Adjusted effects of PAS score and volitional instability by gender on predicted MCS Score at two yearsFigure 3.Adjusted effects of PAS score and volitional instability on probability of failure

The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial

Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores. A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks. There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis. TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis.

Poster 138: Hypertrophy of the Anterior Coracoacromial Ligament as an Etiology of Shoulder Pain in the Young Overhead Athlete: The CALPYSO condition

Objectives:Shoulder pain in the young overhead athlete is commonly thought to result from instability and SLAP pathology, but not from a primary subacromial space pathology. We encountered a series of young overhead athletes with shoulder pain not due to instability or SLAP pathology. All had pain at the anterolateral (AL) corner of the acromion. We report the clinical characteristics, pathology, and results of treatment of this previously unreported association.Methods:92 young (mean age 19 [13-26]) overhand athletes presented with shoulder pain unresponsive to conservative treatment. There were 54 (59%) males and 38 (41%) females. 76% had pain at the AL acromial corner. 71% had pain with an overhand arc of motion from Abd/ER to Abd/IR position. 53% had SLAP-type physical exam findings, but none had instability symptoms. Patients most commonly participated in the following sports: Baseball 38.5%, Swimming 16%, Softball 15%, and Volleyball 11%.Pre-op mean scores were: ASES= 60, SST= 7.5, and VAS pain= 4.3. All underwent EUA and arthroscopy. There was no evidence of instability or SLAP pathology. All had varying degrees of subacromial bursitis. But, the primary pathology was a thickened anterior CA ligament (CAL). The hypertrophic CAL inserted on the acromion, but also extended far laterally under the deltoid muscle. This formed an “awning” at the AL acromial corner which resulted in significant subacromial space compromise. The hypertrophic CAL anterior edge and lateral extension was excised and bursectomy performed in all and in 90% an osseous acromioplasty was performed as well. There were associated pathologic findings: 15 (16%) had posterior capsular contracture with GIRD, 10 (11%) had a posterior labral split tear at the equator of the glenoid.Results:At average follow-up of 2.2 years (1-5), all had returned to the former level of overhead sport activity. Rapid rehabilitation was possible and average time to return to sport was 19 weeks (8-52, SD 10.2). Seventy-five (81.5%) returned to the same level of sport. At final follow-up, mean VAS decreased from a preoperative level of 3.7 (SD 2.5, range 0-8) to a postoperative level of 0.6 (SD 1.1, range 0-4) (p<0.0001). Mean ASES score improved 30.7 points after surgery, corresponding to an improvement from a preoperative level of 63.1 (SD 19.7, range 26.7-100) to a postoperative level of 93.8 (SD 9.3, range 73.3-100) (p<0.0001). Simple shoulder test (SST) scores also improved from a preoperative level of 8.8 (SD 3.1, range 0-12) to a postoperative level of 11.6 (SD 1.0, range 8-12) (p<0.0001). There were no complications, re-operations, and no occult instability was revealed.Conclusions:Younger age (avg 19 yrs, high school and collegiate athletes) participating in overhand sports, typically year-round were defining, consistent factors in this patient population. Female athletes made up a substantial 41% of the series.We feel that symptomatic, hypertrophic anterior CAL is a variant of impingement, most likely due to use and overuse in a repetitive overhead sport. Overuse is recognized as an etiology for shoulder pathology including instability, SLAP lesion, and labral injury, but subacromial pathology is more thought of as a condition of an older age group. This clinical entity in this series, we feel, is another form of overuse pathology and is a primary subacromial space pathology. It was not secondary to occult instability or posterior capsule tightness or SLAP pathology. Thus, not all shoulder problems in young, overhead athletes should be attributed to occult instability or SLAP pathology.We have developed a mnemonic for this clinical entity: CALYPSO. C: Coracoacromial ligament A: Anterior band hypertrophy and L: Lateral extension under the deltoid. Y: Youth (high school and college age) P: Posterior capsular contracture and labral pathology. S: Subacromial bursitis; O: Overuse and Overhead sportClinicians should maintain a high index of suspicion for this clinical entity when evaluating young overhead athletes. In all cases, arthroscopy was successful in identifying and treating the pathology and all athletes were able to return to their previous level of sport.

A novel sternoclavicular hook plate for treatment of proximal clavicle fracture with dislocation of sternoclavicular join

PurposeThe aim of this study was to explore the efficacy of sternoclavicular hook plate for treatment of proximal clavicle fracture with dislocation of sternoclavicular joint.MethodsBetween October 2016 and December 2020, 16 cases (9 male and 7 female patient, with a mean age of (42 ± 10) years) of proximal clavicle fracture with dislocation of sternoclavicular joint were included in the study. Injured side, injury mechanism, time to surgery, Complications and duration of follow-up were recorded. The outcomes were evaluated with radiographic assessment, American Shoulder and Elbow Surgeons’ Form (ASES). All the patients were evaluated on postoperative 3rd, 6th, and 12th months.ResultsAccording to the ASES scoring system, the average score was 49 ± 4 (preoperative score), 87 ± 5 (3 months follow-up), 88 ± 3 (6 months follow-up) and 91 ± 3 (12 months follow-up). Statistics differences was showed between preoperative and 3,6,12 months follow-up score of ASES score (p < 0.001). The postoperative physical function was better than the preoperative function. Internal fixation failure and fracture non-union complications in two patients.ConclusionOur study indicates that open reduction and sternoclavicular hook plate fixation for the treatment of traumatic sternoclavicular fracture is a safe, relatively straightforward surgical procedure that can lead to satisfactory outcomes.

The Role of Humeral Neck-Shaft Angle in Reverse Total Shoulder Arthroplasty: 155° versus

The aim of this study was to have updated scrutiny of the influence of the humeral neck-shaft angle (HNSA) in patients who underwent reverse shoulder arthroplasty (RSA). A PRISMA-guided literature search was conducted from May to September 2021. Clinical outcome scores, functional parameters, and any complications were reviewed. Eleven papers were identified for inclusion in this systematic review. A total of 971 shoulders were evaluated at a minimum-follow up of 12 months, and a maximum of 120 months. The sample size for the “HNSA 155°” group is 449 patients, the “HNSA 145°” group involves 140 patients, and the “HSNA 135°” group comprises 291 patients. The HNSA represents an important variable in choosing the RSA implant design for patients with rotator cuff arthropathy. Positive outcomes are described for all the 155°, 145°, and 135° HSNA groups. Among the different implant designs, the 155° group show a better SST score, but also the highest rate of revisions and scapular notching; the 145° cohort achieve the best values in terms of active forward flexion, abduction, ASES score, and CMS, but also the highest rate of infections; while the 135° design obtains the best results in the external rotation with arm at side, but also the highest rate of fractures. High-quality studies are required to obtain valid results regarding the best prosthesis implant.

Arthroscopic release of the pectoralis minor tendon from the coracoid for pectoralis minor syndrome

PurposeThe term “pectoralis minor syndrome” refers to this constellation of symptoms that can occur when the pectoralis minor (Pm) is shortened and contracted. Release of the tendon of the Pm from the coracoid has been reported to provide substantial clinical improvement to patients presenting with pectoralis minor syndrome. The purpose of this study was (1) to describe the technique for endoscopic release of pectoralis minor tendon at the subdeltoid space, (2) to classify the pectoralis minor syndrome according to its severity and (3) and to report the short-term outcomes of this procedure in a consecutive series of patients diagnosed with pectoralis minor syndrome.MethodsEndoscopic release of the pectoralis minor tendon was performed in a series of 10 patients presenting with pectoralis minor syndrome. There were six females and four males with a median age at the time of surgery of 42 (range from 20 to 58) years. Four shoulders were categorized as grade I (scapular dyskinesis), and six as grade II (intermittent brachial plexopathy). Shoulders were evaluated for pain, motion, satisfaction, subjective shoulder value (SSV), quick-DASH, ASES score, and complications. The mean follow-up time was 19 (range, 6 to 49) months.ResultsArthroscopic release of the tendon of the Pm led to substantial resolution of pectoralis minor syndrome symptoms in all but one shoulder, which was considered a failure. Preoperatively, the median VAS for pain was 8.5 (range, 7–10) and the mean SSV was 20% (range, 10% - 50%). At most recent follow-up the mean VAS for pain was 1 (range, 0–6) and the mean SSV 80% (range, 50% - 90%). Before surgery, mean ASES and quick-DASH scores were 19.1 (range, 10–41.6) and 83.1 (range, 71 and 95.5) points respectively. At most recent follow-up, mean ASES and quick-DASH scores were 80.1 (range, 40–100) and 19.3 (range, 2.3–68) points respectively. No surgical complications occurred in any of the shoulder included in this study.ConclusionsEndoscopic release of the tendon of the pectoralis minor from the coracoid improves pain, function and patient reported outcomes in the majority of patients presenting with the diagnosis of isolated pectoralis minor syndrome.

Antegrade intramedullary locking nail in the management of proximal and middle thirds of humeral diaphyseal fractures.

The aim of the study was to evaluate the antegrade intramedullary locking nail osteosynthesis for the treatment of the proximal and middle thirds of humeral shaft fractures. A retrospective study was made on 218 patients diagnosed with humeral diaphysis fractures who undergo surgery with antegrade intramedullary locking nail between January 2017 and December 2021. The clinical follow-up started two days after surgery and continued at one month, threemonths, sixmonths and one year. The functional recovery evaluation was performed using visual analogue scale (VAS) score, Rating Scale of American Shoulder and Elbow Surgeons Form (ASES), Mayo Elbow Performance Score System (MEPS) and rate of complications. Low intra-operative blood loss, short operation time, short hospitalisation, early mobilisation of the patient and high union rate imposed intramedullary nailing as a standard procedure for the treatment of proximal and middle thirds of humeral diaphyseal fractures in the past years, and the union rate was 99.5%. VAS score evaluated at one month, three months and six months indicated a very good overall post-operative experience. The ASES and MEPS score were evaluated at six months and oneyear and showed excellent results. All the patients (except 1 case) were able to return to their previous jobs within sixmonths. Humeral nailing is associated with early return to function of the upper limb, with very good clinical and functional outcomes of the shoulder and elbow. This method could be considered the best surgical option for the management of proximal middle humeral fractures.

Bioinductive collagen implants facilitate tendon regeneration in rotator cuff tears.

PurposeTo evaluate the clinical outcomes, MRI imaging and histological characteristics of biopsy samples of the tendon from patients in whom rotator cuff repair was previously performed with a bioinductive type I bovine collagen implants.MethodsProspective study of 30 patients with partial or complete rotator cuff tears who underwent arthroscopic repair and augmentation with a resorbable type I bovine collagen implant. Preoperatively and at 6 and 12 months after surgery, the VAS, ASES and Constant-Murley scores were evaluated and an MRI study was performed. At 6 months, biopsies of the resulting tissue were obtained and examined histologically.ResultsPatients experienced statistically significant and sustained improvement from baseline for all scores and the mean tendon thickness increased by 1.84 mm. Magnetic resonance imaging evidence of complete healing was found in 27 patients and a considerable reduction in defect size, greater than 50%, was shown in 3. In all samples obtained, the new tissue generated had the histological appearance of a tendon, and was indistinguishable from the native tendon. There was no evidence of any remaining collagen implant.ConclusionsBiopsies of tissue formed from bioinductive type I bovine collagen implants showed, six months after surgery, the generation of a neotendon indistinguishable from the native one. Histology and MRI imaging, revealed complete integration of the implant and absence of inflammatory or foreign body reactions. The clinical parameters, thickness and MRI signal of the tendon improved significantly at 6 months, regardless of the type and size of the tear, and remained unchanged until 12 months.Level of evidenceLevel IV, case series.

Humeral offset as a predictor of outcomes after reverse shoulder arthroplasty.

The Grammont-style reverse shoulder arthroplasty (RSA) relies on medialization and distalization of the shoulder center of rotation. Lateralized designs have recently gained popularity. The amount of lateralization, however, remains a controversial topic. The purpose of this study was to correlate the change in humeral offset (HO) with outcomes and complications following RSA. We hypothesized that a lateralized HO following RSA would be associated with improved range of motion (ROM), better patient-reported outcomes (PROs), and fewer complications. A consecutive series of 104 patients (109 shoulders) was retrospectively evaluated. All patients underwent primary RSA by 2 shoulder and elbow fellowship-trained orthopedic surgeons at 2 different centers. Inclusion criteria was a primary RSA with at least 1-year follow-up. All patients had the HO measured on a preoperative and a postoperative Grashey radiograph, and the change in HO was calculated (ΔHO=PostHO-PreHO). A negative value was defined as a medialized HO and a positive value as a lateralized HO. ROM and primary outcomes, including forward elevation (FE), external rotation (ER), internal rotation (IR), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, were collected. Complications and revisions were also reported. The mean age was 72 years with a mean follow-up of 22.3 months. The average FE (92° vs. 148°), ER (34° vs. 44°), SSV (35% vs. 87%), and ASES score (37.2 vs. 81.2) increased significantly (all P<.01) compared with preoperative values. The HO was medialized postoperatively in 63 shoulders and lateralized in 46 shoulders. No statistically significant differences in the mean values for postoperative FE (147° vs. 146°, P=.892), ER (43° vs. 45°, P=.582), IR (L3 vs. L3, P=.852), SSV (88% vs. 85%, P=.476), and ASES score (81.3 vs. 81.1, P=.961) were found between the groups. However, there was significantly more improvement in ER in the lateralized HO cohort than the medialized cohort (16° vs. 7°, P=.033). Six shoulders, 5 medialized and 1 lateralized HO, demonstrated scapular notching and remained asymptomatic. Five shoulders, 4 medialized and 1 lateralized HO, experienced at least 1 instability incident, and 2 shoulders with medialized HO had an acromion/scapular spine fracture. Overall, 2 shoulders with medialized HO underwent revision surgery because of instability. Although RSA provides significant improvement in ROM and PROs regardless of postoperative HO, restoring baseline HO or lateralization beyond baseline may be favorable for improving ER and decreasing complications following RSA.

Establishing maximal medical improvement following aseptic revision of shoulder arthroplasty.

Shoulder arthroplasty surgery volume continues to increase yearly. As the prevalence of shoulder replacement continues to rise, there will be a growing number of revision surgeries performed for a variety of indications. Understanding patient outcomes and recovery time following these procedures is critical, particularly as it relates to revision surgery, which generally has worse outcomes and longevity than primary arthroplasty. The point at which the peak of potential improvement is reached can be defined as the point of maximal medical improvement (MMI). The timing to MMI has previously been reported in the literature following both primary anatomic and reverse total shoulder arthroplasty. However, to our knowledge, timing to MMI following revision shoulder arthroplasty has not been defined. The purpose of the present study, therefore, is to establish the time to MMI following aseptic revision shoulder arthroplasty using validated patient-reported outcome measures. A retrospective cohort study was conducted following patients who underwent aseptic revision shoulder arthroplasty over a defined 3-year period. Multiple fellowship-trained shoulder and elbow surgeons from a single institution performed all operations. Those with at least 24 months of follow-up and multiple time points of postoperative patient-reported outcome scores were included in the analysis. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores and Single Assessment Numeric Evaluation (SANE) scores were prospectively recorded and followed over time. Exclusion criteria included revision surgeries done for infection, staged procedures following infection, and revision for periprosthetic fracture. Twenty-two patients met inclusion criteria. The mean preoperative ASES and SANE scores were 41.8 and 30.5, respectively. There was a trend toward improvement in both the ASES and SANE scores through the 6-9-month postoperative follow-up point, at which point clinically significant improvement was achieved, with mean values of, respectively, 76.9 and 81.2. No further improvement was achieved 9 months after surgery, although scores were generally maintained through an average final follow-up of 30 months, with final ASES and SANE scores of 70.1 and 67.8, respectively. Following aseptic revision shoulder arthroplasty, clinically significant improvements in patient-reported outcome scores are seen up to 9 months postoperatively, the point at which MMI is achieved. These findings serve to guide clinicians in counseling patients regarding their expected postoperative recovery following revision shoulder arthroplasty.

Mid- to long-term outcomes of augmented and nonaugmented anatomic shoulder arthroplasty in Walch B3 glenoids.

In cases of severe osteoarthritis, posterior glenoid wear leads to acquired retroversion of the glenoid. Surgical treatment of glenoids with acquired retroversion and posterior humeral subluxation with anatomic total shoulder arthroplasty (aTSA) is controversial. The purpose of this study was to determine mid- to long-term outcomes and reoperation rates of augmented and nonaugmented aTSA for treatment of glenohumeral osteoarthritis with Walch B3 glenoid deformity. This observational cohort study reviewed patients with a Walch B3 glenoid undergoing aTSA at a single institution between 2007 and 2014. Patients were contacted to complete updated patient-reported outcome measures at a minimum of 6 years postoperatively. Outcome measures collected included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score and Single Alpha Numeric Evaluation (SANE) score. Secondary outcomes included any additional surgery on the operative shoulder, patient satisfaction, and willingness to undergo aTSA again. Thirty-nine patients met inclusion criteria, and thirty-five (89.7%) were able to be contacted for final outcomes evaluation. Mean follow-up was 8.7 years (range 6-13) after surgery. Sixteen patients were treated with an augmented glenoid component, and 19 patients were treated with a standard glenoid component. Of those with standard components, all were partially corrected with asymmetric reaming. At final follow-up, there were no statistically significant differences between those with augmented and standard glenoid components for mean ASES score (93.3 vs. 85.7, P=.217), ASES pain score (47.2 vs. 41.6, P=.161), SANE score (87.8 vs. 86.0, P=.692), and percentage patient satisfaction (95.6% vs. 96.8%, P=.735), forward elevation (148° vs. 149°, P=.852), or external rotation (36° vs. 39°, P=.202). No patient in either group had undergone revision surgery of the operative shoulder over the study period and all patients stated that they would undergo the same surgery again. Both augmented and standard aTSA can provide satisfactory and sustained improvements in patient-reported outcomes in patients with acquired glenoid retroversion due to glenohumeral osteoarthritis. Despite a trend toward alternative treatment options, anatomic shoulder arthroplasty should remain a surgical consideration even in the setting of a Walch B3 glenoid deformity.

Functional and radiologic results of the crimson duvet procedure in rotator cuff treatment: a randomized controlled clinical trial.

Rotator cuff tears are one of the more frequent pathologies of the shoulder. Arthroscopic techniques and biologic augmentation have been developed to improve the rate and quality of healing. The crimson duvet procedure (CDP) theoretically provides mesenchymal stem cells through microfracture treatment of the footprint. The aim of this research was to evaluate the effect of CDP in patients who had undergone arthroscopic surgery for complete rotator cuff repair. A prospective randomized clinical trial was performed in a total of 123 patients, consisting of 59 women and 64 men, with a mean age of 58 years. We included patients with a clinical and radiologic diagnosis of a complete rotator cuff tear. All patients were treated with arthroscopic rotator cuff repair. In group 1, the surface of the footprint was débrided; in group 2, the footprint underwent microfracture. The primary outcome was the nonhealing rate, which was detected by magnetic resonance imaging (MRI) or ultrasonography, and the secondary outcome was the functional result. A Sugaya classification of I to III was considered to indicate healing. For clinical evaluation, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Constant scores were evaluated, along with the range of motion. The functional evaluation was performed preoperatively and at 6 months and 1 year postoperatively. The radiologic (MRI or ultrasonography) evaluation was performed at 6 months. Neither the patients nor the radiologists and physical therapists who performed the postoperative evaluations were informed of the random selection. We observed a healing rate of 85.11% in the control group and 93.7% in the CDP group, which was not significant (P=.19). However, a significant improvement in function was observed in all patients. The ASES score improved from 68.9 (SD 13.8) preoperatively to 92.2 at 6 months and to 96.4 (SD 6.2) at 12 months (P<.05), but no difference was observed between the groups. A similar level of improvement was observed in the Constant score. The arthroscopic repair of complete rotator cuff tears presents good and excellent clinical results in most patients. Nevertheless, nonhealing occurs at a rate that depends mainly on the age of the patient and the size of the tear. The addition of CDP did not improve the functional results or the healing rate.

Recall Bias in Retrospective Assessment of Preoperative American Shoulder and Elbow Surgeons Scores After Reverse Total Shoulder Arthroplasty.

Although reverse total shoulder arthroplasty (RTSA) has been shown to be effective for the treatment of cuff tear arthropathy (CTA), the patient's inability to accurately recall their preoperative shoulder condition could skew their perception of the effectiveness of the procedure. Identifying patients who are susceptible to notable recall bias before surgery can help surgeons counsel patients regarding expectations after surgery. The purpose of this study was to evaluate whether patients who undergo RTSA are susceptible to recall bias and, if so, which factors are associated with poor recollection. Patients who underwent RTSA for CTA by the senior author between September 2016 and September 2018 were identified. All patients completed the American Shoulder and Elbow Surgeons (ASES scores) Standardized Assessment Form at the time of preoperative assessment. Patients were contacted at a minimum of 24 months after surgery to retrospectively assess their preoperative condition. A total of 72 patients with a mean age of 72.2 ± 7.65 years completed a retrospective shoulder assessment at 28.3 ± 7.3 months postoperatively. Patient assessment of shoulder condition showed poor reliability (intraclass correlation coefficient = 0.453, confidence interval, 0.237-0.623). Greater preoperative shoulder ASES scores were associated with a greater difference between preoperative ASES scores and recall ASES scores (β = 0.275, P < 0.001). Patients who undergo RTSA for CTA are susceptible to clinically significant recall bias. Patients with better preoperative condition recall worse preoperative shoulder conditions compared with patients with worse preoperative conditions and are susceptible to a higher degree of recall bias. This patient population should be identified preoperatively and have notable counseling before and after surgery to help them better understand their disease burden and what to expect after surgical intervention. III, diagnostic cohort study.

Quality of life and HIV adherence self-efficacy in adolescents and young adults living with perinatal HIV in Chiang Mai, Thailand

ABSTRACT We assessed the quality of life and HIV adherence self-efficacy of adolescents and young adults (AYA) with perinatal HIV infection (PHIV). This cross-sectional study was conducted in Chiang Mai, Thailand. AYA-PHIV aged between 15 and 25 years were enrolled, who all were initiated on antiretroviral treatment as children. The World Health Organization-quality of life-BREF questionnaire and the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES) were administered. A total of 111 AYA-PHIV were included, including 52 (47%) females. Their median age was 20.2 ± 2.6 years. The overall QOL was rated as favorable (good or very good) by 59.4% of AYA-PHIV. The highest score was seen in the social relationships domain followed by the environmental health domain. Males had a significantly lower score in the psychological health domain than females (p = 0.018). Simple linear regression revealed a negative association between male sex, physical, and psychological health domain scores. The overall mean HIV–ASES score was 7.79 ± 1.96 out of 10, with a trend toward lower scores in males (p = 0.062), and a weak positive correlation with QOL. Our study documented worse QOL and lower HIV adherence self-efficacy in male AYA-PHIV. The findings call for the design of tailored male-focused interventions.

Leukocyte-rich and Leukocyte-poor Platelet-rich Plasma in Rotator Cuff Repair: A Meta-analysis

To systematically review of randomized controlled trials (RCTs) to compared the effects of leukocyte-rich and leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair. Two independent reviewers comprehensively searched PubMed, Embase, and Cochrane library databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparison of leukocyte-rich platelet-rich plasma or leukocyte-poor platelet-rich plasma in rotator cuff repair in a level I RCTs. Methodological quality assessment was carried out using Cochrane Review Manager 5.3 software. P<0.05 was considered statistically significant. Nine RCTs with 540 patients were included in this review. Meta-analysis showed that leukocyte-poor platelet-rich plasma in significantly reduced retear rate in rotator cuff repair [RR=0.56 95% CI (0.42, 0.75); P<0.05), and in clinical results, the constant score [MD=3.67, 95% CI (1.62, 5.73); P=0.0005], UCLA score [MD=1.60, 95% CI (0.79, 2.42); P=0.0001], ASES score [MD=2.16, 95% CI (0.12, 4.20); P=0.04] were significantly improved. There was a significant result in favor of PRP for the Constant score [MD=-1.24, 95% CI (-1.50, -0.99); P<0.00001], while SST scores were not significantly different among all groups [MD=0.21, 95% CI (-0.21, 0.64); P=0.32]. In conclusion, leukocyte-poor platelet-rich plasma can improved the clinical function and reduced retear rate in arthroscopic rotator cuff repair. In contrast, the efficacy of leukocyte-rich platelet-rich plasma was not significantly improved with the exception of VAS score.