ASES Score Research Articles

Prior Shoulder Arthroscopy is Associated with Inferior Clinical Outcomes Following Primary Reverse Shoulder Arthroplasty for Rotator Cuff Tear Arthropathy

Background Various patient-related and condition-related factors can influence the clinical benefits of reverse shoulder arthroplasty (RSA). With the emergence of new potential joint-preserving arthroscopic interventions, understanding the impact of shoulder arthroscopy prior to RSA is increasingly relevant. Therefore, the purpose of this study was to understand the impact of previous ipsilateral shoulder arthroscopy on outcomes and shoulder function following RSA for rotator cuff tear arthropathy. Methods Patients who underwent RSA for rotator cuff tear arthropathy from June 2016 to September 2020 by a single surgeon were retrospectively reviewed from a prospectively collected clinical database. Patients were separated into two groups: 1) patients who underwent RSA following prior ipsilateral shoulder arthroscopy (RSAPA) and 2) patients who underwent RSA without previous shoulder surgery (RSA). Patient-reported outcomes (PROs), including SST, ASES, UCLA score, SAS score, and active shoulder range of motion were measured preoperatively and at a minimum 2 years postoperative. Results A total of 103 patients (n=38 RSAPA and n=65 control RSA) were analyzed. The mean duration of follow-up for patients with prior ipsilateral shoulder arthroscopy was significantly shorter compared to the control patients (RSAPA=33 months and RSA=50 months, p < 0.0001). All PROs improved postoperatively (p < 0.001). Improvements in PROs for RSAPA were diminished relative to RSA control group patients, including SST (RSAPA=5.4 vs RSA=7.6, p = 0.005), ASES (RSAPA=40.8 vs RSA=54.7, p = 0.021), and UCLA (RSAPA=16 vs RSA=20.7, p = 0.009) scores. Improvements in forward flexion (RSAPA=69° vs RSA=95°, p = 0.0003) and abduction (RSAPA= 67° vs RSA=83°, p = 0.003) were decreased in the RSAPA group compared to the control group (RSA). One patient (1.5%) with prior shoulder arthroscopy required revision due to recurrent instability, whereas no patients in the control group required revision surgery (p=0.25). Conclusion Patients with rotator cuff tear arthropathy who underwent RSA following prior shoulder arthroscopy demonstrated significant improvements in function and patient-reported outcomes, but these outcomes are diminished compared to those patients with no history of surgery.

Outpatient versus inpatient total shoulder arthroplasty: A meta-analysis of clinical outcomes and adverse events.

In recent years, orthopaedic procedures have increasingly shifted from inpatient to outpatient settings. This trend includes total shoulder arthroplasty (TSA), which is being performed more frequently in outpatient facilities and ambulatory surgical centres. The purpose of this study was to compare the clinical outcomes and rates of adverse events between outpatient and inpatient TSA. PubMed, Cochrane, and Google Scholar (pages 1-20) databases were screened for articles comparing outpatient to inpatient TSA through June 2024, using relevant and holistic search terms. Non-comparative articles and those utilizing national databases were excluded from our study. Data on complications, myocardial infarction (MI), thromboembolic events, anaemia/transfusions, infections, readmissions, emergency department (ED) visits, revision surgery, and patient reported outcome measures at one year (Visual Analog Scale [VAS] and American Shoulder and Elbow Surgeons [ASES] score) were extracted. A total of 14 articles were included in our study, involving 1070 outpatient and 1330 inpatient TSA patients. Patients in the inpatient group were older and had a higher ASA compared to the patients in the outpatient group. The outpatient TSA group was found to have significantly lower rates of overall complications (odds ratio [OR] = 0.59, p = 0.001), medical complications (OR = 0.43, p < 0.001), and readmissions (OR = 0.47, p = 0.008), as well as higher mean ASES scores (81.4 vs. 78.5, p = 0.01) when compared to the inpatient TSA group. There were no significant differences in rates of ED visits (p = 0.27), revisions (p = 0.06), and VAS scores (p = 0.15) between inpatient and outpatient TSA groups. TSAs performed in the outpatient setting had a lower rate of overall adverse events, medical complications, readmissions, and a higher ASES score compared to inpatient TSAs. However, since patients in the inpatient group had higher ASA and were older, our results support the safety of the outpatient TSA based on the current selection criteria.

Short-Term Clinical Results of Middle Trapezius Tendon Transfer with Achilles Tendon Allograft for Irreparable Supraspinatus Tears

BackgroundAmong emerging options, Middle Trapezius Tendon (MTT) transfer has shown promise, particularly in isolated supraspinatus irreparable rotator cuff tears (ISIRCTs) and nonarthritic shoulders unsuitable for reverse total shoulder arthroplasty. This study aims to assess clinical and radiological results of MTT transfer utilizing an Achilles tendon allograft for ISIRCTs. MethodsWe retrospectively reviewed patients who received MTT transfer using Achilles tendon allograft for ISIRCTs between May 2020 and August 2021. Clinical assessments using pain VAS, Constant, ASES, UCLA, and SANE score were assessed pre- and postoperatively. Active Range of Motion (aROM) were obtained, and radiologic assessments included AHD, Hamada grade, and MTT integrity. Results18 patients were involved with mean age of 63.8 ± 7.1, followed for an average of 25.4 ± 4.4 months. Significant improvements were observed in pain relief (VAS:4.7±1.5 to 1.6±0.9, P<.001), shoulder function (Constant: 53.1±11.1 to 70.0±15.1, ASES: 57.7±13.5 to 78.2±17.0, UCLA: 13.6±4.5 to 22.0±6.4; all P<.001), and patient satisfaction (SANE: 51.3±14.1 to 73.7±15.0, P<.001). Active range of motion significantly improved in Forward elevation (FE) and abduction (ABD). Radiologic assessments showed no significant change in AHD and Hamada grade, with p-values of 0.503 and 0.260, respectively. ConclusionMTT transfer using Achilles tendon allograft showed improvement in pain relief, clinical scores, and active FE and ABD in patients with ISIRCTs. However, the validation of its effectiveness necessitates multicenter and long-term studies.

Comparing the Exactech Equinoxe Reverse TSA for Fracture versus Degenerative Conditions: Five-Year Minimum Follow-Up

Reverse total shoulder arthroplasty (rTSA) has become the operative treatment of choice for acute proximal humerus fractures in the elderly population, but little data exists on the long-term outcomes or how they compare to rTSA done for degenerative conditions. The purpose of this study is to compare the clinical and radiographic outcomes of patients undergoing rTSA for acute fracture versus degenerative conditions with a minimum 5-year follow-up. Data was extracted from an international registry of patients with the Exactech Equinoxe rTSA implant from 2007-2018. Patients with a minimum follow-up of 5 years were then split into fracture and degenerative cohorts and matched 1:3 based on age, sex, and follow-up duration. Clinical and radiographic outcomes were compared between the cohorts including range of motion (ROM), patient-reported outcome measures (PROM), VAS pain score, complication and revision rates, implant characteristics, and scapular notching. This data was analyzed using Welch's t-test, Fisher's exact test, or Wilcoxon rank sum test. There were 384 total patients included in the study, with 96 fractures and 288 degenerative. At a mean follow-up of 6.4 years, the degenerative cohort had significant improvements in all PROMs and ROM, compared to their preoperative status. At the latest follow-up, the mean ASES score was 83 and the mean VAS pain score was 1.1 for both cohorts. Patients with degenerative indications had greater forward elevation which did not meet the minimally clinically important difference and greater internal rotation which did not meet the substantial clinical benefit threshold. Patient satisfaction was very high for both cohorts, with 97% in the degenerative cohort and 91% in the fracture cohort satisfied with the procedure (p=0.276). Complication and revision rates were similar between the two cohorts. Patients in the fracture cohort had a larger glenosphere diameter (p=0.045) and greater combined liner/tray offset (p=0.05). Patients in the elective cohort more frequently required an augmented baseplate (p<0.001). Scapular notching was 11% in the degenerative cohort and 9% in the fracture cohort (p=0.82). This study demonstrates no significant differences in the clinical or radiographic outcomes at a minimum of 5 years follow-up for patients undergoing rTSA for acute fracture versus degenerative conditions. Patients undergoing rTSA for either indication have similar rates of complications, revisions, and scapular notching, with high patient satisfaction. Patients undergoing rTSA for an acute fracture can expect similar results to those undergoing rTSA for degenerative conditions at minimum 5-year follow-up.

The Clinical Utility of the Seated Wall Angel as a Test with Scoring.

The seated wall angel (SWA) is an intervention to improve upper quarter mobility but has not been described as a clinical test with scoring. To explore the clinical utility of the SWA as a test with scoring. The authors hypothesized that SWA test scores would be lower on the injured than uninjured side, improve over time, and show stronger association with patient-reported shoulder function than shoulder mobility tests. Prospective cohort. Patients diagnosed with anterior shoulder instability and referred to physical therapy participated. Testing occurred after physical therapy examination (initial) and six weeks later (follow-up). Rehabilitation was not controlled. Testing included clinical tests (SWA, passive shoulder external rotation range of motion, total arc of motion) and patient-reported outcomes including the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, (ASES) and the Western Ontario Shoulder Instability Index (WOSI). The SWA test was scored 0 to 3 points bilaterally based on number of body contacts with the wall (i.e., elbows and fingertips, posterior fingers, posterior forearm). Passive range of motion was measured with a standard goniometer. SWA scores were compared between sides at initial testing and compared between testing timepoints on the injured side. Associations among injured side clinical test values and patient-reported outcome scores were examined. Mean (SD) SWA score on the injured side was significantly lower than the uninjured side at initial testing [1.6 (1.0) vs 2.2 (1.1), p = 0.045] and significantly increased at follow-up testing [2.4 (1.0), p = 0.041]. Only SWA test score was significantly correlated with ASES (r=0.597) and WOSI (r=-0.648) scores at initial testing, and SWA test score was significantly correlated with WOSI score at follow-up testing (r=-0.611). The clinical utility of the SWA test is supported by distinguishing the injured and uninjured sides and having stronger associations with patient-reported shoulder function than shoulder mobility tests.

Complications after Reverse Total Shoulder Arthroplasty in the Korean Population: A Single Center Study of 299 Cases

BackgroundKnowledge regarding differences in the order of frequency of complications after reverse total shoulder arthroplasty (RTSA) between Asian and Western populations is limited. We therefore asked for (1) What is the order of frequency of complications after primary RTSA in the Korean population? (2) What are the rates of complication, reoperation, and revision, and clinical outcomes after index surgery? MethodsWe retrospectively reviewed the 299 consecutive cases who underwent primary RTSA with more than 1 year of follow-up over a period of 12 years. The mean age of the patients was 73.4 years (range, 58-88 years) and the mean follow-up period was 3.8 years (range, 1-11.5 years). Evaluation of the clinical outcomes, complications, and reinterventions was performed at the final follow-up. ResultsThe mean VAS pain score, UCLA score, ASES score, and SSV improved from 6.7, 10.2, 30.7, and 27.7% before RTSA to 1.4, 26.4, 80.5, 77.2% after RTSA, respectively (P < .001). Overall, 45 complications (15.1%) were observed in 44 patients. The order of frequency of complications was as follows: 16 cases of scapular stress fracture (5.4%), 9 intraoperative or postoperative periprosthetic fracture (3.0%), 6 brachial plexus injury (2.0%), 4 instability (1.3%), 2 glenoid loosening (0.7%), 2 glenoid disassembly (0.7%), 2 periprosthetic joint infection (0.7%), 1 glenoid fixation failure (0.3%), 1 humeral stem fixation failure (0.3%), 1 hematoma (0.3%), and 1 complex regional pain syndrome (0.3%). Reintervention was performed in 15 cases (5.0%) including reoperation (8 cases; 2.7%) and revision surgery (7 cases; 2.3%). ConclusionAt a mean follow-up period of 3.8 years, primary RTSA showed satisfactory clinical outcomes with a complication rate of 15.1%, a reoperation rate of 2.7%, and a revision rate of 2.3%. Scapular stress fracture appears to be the most common complication after RTSA in the Korean population.

Do Constrained Liners (in a 145° onlay implant) Provide Any Benefit? A Matched Retrospective Study

The purpose of this study was to compare the outcomes of primary reverse total shoulder arthroplasty (rTSA) using constrained liners (in a 145° onlay implant, Exactech, Equinoxe) with primary rTSA using standard liners with a minimum 1-year follow-up. A total of 836 primary rTSA patients were analyzed in this study. Patients treated with constrained liners (n=209) were cross-matched 1:3 for age, gender, glenosphere diameter, and follow-up duration, and compared with 627 patients who underwent primary rTSA with standard liners. Study endpoint was at one year. Outcomes were analyzed preoperatively and at the latest follow-up. Patient characteristics, postoperative range of motion (ROM), patient reported outcomes (PROs), complications and revisions were recorded. There was no statistically significant changes in improvement in pain (-4.9 vs -5.1; p=0.356), ROM (abduction, 45.7° vs 47.9°; p=0.522) (forward elevation, 44.0 vs 50.8°; p=0.057) (internal rotation score 1.0 vs 1.1; p=0.709) (external rotation, 17.9° vs 16.7°; p=0.543), or PROs (American Shoulder and Elbow Surgeons Score, 44.5 vs 43.7; p=0.107) (Shoulder Arthroplasty Smart score, 27.5 vs 30.0; p=0.052) between the constrained and standard liner cohorts at minimum 1 year follow-up. However, the constrained liner rTSA cohort had a significantly higher rate of adverse events (6.2% vs. 2.7%; p=0.012), including a higher rate of scapular notching (15.6% vs. 8.8%; p=0.015). The utilization of constrained liners in primary rTSA demonstrated no significant difference in the change in pain, abduction, forward elevation, ER and IR scores, ASES scores, and SAS scores at minimum 1-year follow-up. There was no significant difference in forward elevation or abduction compared to standard liners. However, we observed that the overall rate of adverse events, including scapular notching were significantly higher in the constrained liner cohort. Long-term clinical and radiographic follow-up is necessary to fully elucidate the durability of these results. At this time, it is unclear if constrained liners have any benefit in rTSA.

A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures

BackgroundThe purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it’s efficacy with that of traditional surgical intramedullary nail treatment.Materials and methodsThis was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant–Murley score) between the two groups of patients.ResultsThere was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001).ConclusionRobot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes.

Non-vascularized coracoid process autograft for glenoid reconstruction in revision shoulder arthroplasty.

To report the radiological and clinical outcomes of non-vascularized coracoid process autografts used for glenoid reconstruction during revision shoulder arthroplasty. This is a retrospective, monocentric study from January 2016 to October 2022 targeting patients treated with a coracoid bone graft for glenoid reconstruction during revision of shoulder arthroplasty. The primary outcome measures were coracoid graft union rate and graft-implant osseointegration. Secondary outcome measures included clinical and CT-scan identified radiological complications and functional outcomes as measured by the Visual Analog Scale (VAS), Range of Motion (ROM), Subjective Shoulder Value (SSV), Constant score (absolute and ponderate), and ASES score. Fifteen patients (9 males, 6 females; mean age 66.9years, range 38-85) were included. At a mean follow-up of 20.9months (range 12-56months), 93.3% achieved complete graft integration. One case of partial lysis without baseplate loosening was noted. Regarding range of motion, the mean forward elevation was 130° (range 90°-170°), external rotation at the side 25° (range 10°-40°), external rotation in 90° of abduction 45° (range 10°-80°), and internal rotation 52° (range 10-80°). The mean VAS for pain was 1.1 (range 0-8), mean SSV 67.3% (range 40-90%), mean ASES score 85.5 (range 65-98.3), mean Absolute Constant score 58.6 (range 21-83), and mean Ponderate Constant score 77.5% (range 28.8-110.7%). No neurological injuries were reported. Utilizing a non-vascularized coracoid graft during shoulder arthroplasty revision is a safe, reproducible, and time-efficient technique that demonstrated satisfactory osseointegration, implant stability, good functional results, and a low complication rate.

Is revision to anatomic shoulder arthroplasty still an option? A systematic review.

With the historical complications when using total shoulder arthroplasty (TSA) to revise failed arthroplasties, and the success of the reverse prosthesis in the revision setting, the question arises whether revision to TSA is still a reasonable option? This systematic review examines revision to TSA and the factors associated with outcomes. A systematic review was performed for studies of TSA used to revise a failed hemiarthroplasty or TSA. The primary outcome was implant failure leading to a repeat revision arthroplasty. Secondary outcomes included visual analog scale (VAS) pain scores, shoulder motion and other clinical outcomes of shoulder function. Data were pooled to generate representative frequency-weighted means. Thirteen studies were included, totaling 312 shoulders. Etiologies for revision included glenoid arthrosis (62%), glenoid component failure (36%), and other (2%). Of which, 39% of cases experienced complications and 12% required another arthroplasty revision. Secondary outcomes such as VAS pain, Constant, ASES and UCLA score improved, but none were statistically significant. Unsatisfactory outcomes were higher among patients with glenoid bone loss, instability, and soft tissue deficiencies. Revision to anatomic TSA can be an acceptable option in certain patients. However, the high rate of complications and glenoid loosening, makes this a limited approach for a revision to anatomic TSA procedure.

Monobloc vs. Modular Radial-Head Arthroplasty for Complex Elbow Trauma: Long-Term Follow-Up and Comparative Evaluation.

Introduction: Mason Type 3 radial-head fractures are typically treated with open reduction and internal fixation (ORIF) or radial-head arthroplasty (RHA). Prosthetic options include traditional monobloc implants and newer modular implants designed to match patient anatomy. While short- and medium-term outcomes of metallic RHA are generally favorable, this study aims to compare the long-term outcomes of patients treated with monobloc versus modular implants. Methods: The medical records of all the patients who underwent RHA at a level I trauma center between 2000 and 2011 were retrospectively reviewed. Patients who were available for follow-up were invited for reassessment, which included physical examination, questionnaires for the assessment of elbow pain and function, and follow-up radiographs. Results: Out of 35 patients who had RHA, 13 (37%) had a monobloc prosthesis and 22 (63%) had a modular prosthesis. Out of the patients that could be traced, 4 patients from the monobloc group and 10 patients from the modular group agreed to participate in the study. The mean follow-up time was 15 years in the monobloc group and 12.4 years in the modular group. Patients in the modular group demonstrated superior functional outcomes compared to the monobloc group, with statistically significant improvements in MEPS and DASH scores and a non-significant trend towards better ASES scores and VAS scores. Physical examination revealed a decline in function in the operated arm for both groups, with statistically significant differences favoring the modular group in elbow flexion and extension. Radiographic analysis showed varying degrees of implant loosening, with the modular group exhibiting less loosening compared to the monobloc group. Mild degenerative changes and heterotopic ossification were also observed, predominantly in the modular group. Conclusions: The results suggest that modular implants offer superior functional outcomes compared to monobloc implants. The modular group showed statistically significant improvements in elbow flexion and extension. These findings indicate that modular implants may be a more favorable option for enhancing patient outcomes. Further research with larger sample sizes is recommended to confirm these trends and to better understand the long-term benefits of modular implants.

Effects of Melatonin on Sleep Quality and Patient-Reported Outcomes After Arthroscopic Rotator Cuff Surgery: A Prospective Randomized Controlled Trial.

Sleep disturbance is a significant symptom associated with both rotator cuff tears and arthroscopic rotator cuff repair. Melatonin has been shown to be safe and effective in managing multiple sleep disorders, including secondary sleep disorders, with relatively minor adverse effects and lack of addictive potential. To investigate the effects of oral melatonin on postoperative sleep quality after arthroscopic rotator cuff repair. Randomized controlled trial; Level of evidence, 1. This was a prospective randomized clinical trial evaluating patients undergoing arthroscopic rotator cuff repair. Exclusion criteria included history of alcohol abuse, current antidepressant or sedative use, revision rotator cuff repair, severe glenohumeral arthritis, and concurrent adhesive capsulitis. Patients were randomly assigned in a 1:1 ratio to 1 of 2 groups: 5-mg dose of melatonin 1 hour before bedtime or standard sleep hygiene (≥6 hours per night, avoiding caffeine and naps in the evening). Patients in the melatonin group took their assigned melatonin dose for 6 weeks beginning the day of surgery. Patient-reported outcome assessments, including the Pittsburgh Sleep Quality Index (PSQI), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and the Single Assessment Numeric Evaluation (SANE), and pain medication charts were collected preoperatively as well as at 2 weeks, 6 weeks, 3 months, 4 months, and 6 months postoperatively. Numeric variables were analyzed using paired and unpaired t tests, with significance set at P < .05. Eighty patients were included for final analysis (40 in the control group, 40 in the melatonin group). Patient characteristics such as age, sex, race, body mass index, and laterality did not differ significantly (P≥ .05). Preoperative ASES, SANE, and PSQI scores did not differ between groups (P≥ .055). PSQI scores were significantly lower (better quality sleep) in the melatonin group at the 6-week postoperative period (P = .036). There was a positive correlation between how patients rated the intensity of their pain and the PSQI at the 6-week postoperative period (0.566). The PSQI question regarding sleep quality was found to be significantly lower in the melatonin group at the 3-month, 4-month, and 6-month postoperative periods (P = .015, P = .041, and P≤ .05, respectively). SANE scores were significantly lower in the melatonin group (P = .011) at 6 weeks and then higher in the melatonin group (P = .017) at 6 months. ASES scores were significantly higher in the melatonin group at 4 and 6 months (P = .022 and P = .020, respectively). Lastly, patients who were randomized into the melatonin group were found to use significantly less narcotic medication at the 4-month postoperative period (P = .046). Melatonin use after arthroscopic rotator cuff repair led to improved sleep quality (PSQI) in the early postoperative period as well as improved functional outcomes (ASES and SANE scores) and decreased narcotic use in the later postoperative period. Patients with significant sleep disturbances associated with rotator cuff repairs may benefit from the use of melatonin. NCT04278677 (ClinicalTrials.gov identifier).

How To Choose The Best Lateralization And Distalization Of The Reverse Shoulder Arthroplasty To Optimize The Clinical Outcome In Cuff Tear Arthropathy

PurposeLateralization shoulder angle (LSA) and distalization shoulder angle (DSA) are two parameters that had been described for a better planification of the arthroplasty, but the range of these angles are very wide. The purpose of this study was to investigate the best combination in terms of lateralization and distalization to optimize the outcome of Reverse total shoulder arthroplasty(RTSA) for cuff tear arthropathy (CTA) with a functional deltoid. MethodsThis retrospective cohort study, conducted between 2014 and 2018 at a specialized shoulder unit in Paris, focused on patients exclusively treated with RTSA for CTA, ensuring a minimum follow-up of 1 year. The primary outcome measure was the ASES score. Secondary outcome measures included range of motion and patient-reported outcomes at the final follow-up, such as the Constant score, SSV, SST, and VAS. Optimal RTSA outcomes were delineated by scores surpassing the patient's acceptable symptom state (PASS) for ASES, set in literature at 76. Patients were categorized into two groups based on ASES scores at the last follow-up: those below and those above 76. The capabilities of LSA and DSA to predict the outcome of interest were assessed and the corresponding optimal thresholds for having better outcome were calculated using the Receiver Operator Characteristic (ROC) curve. ResultsSixty-two patients were included in the study with a mean age of 74.51 ± 6.79. Correlation analysis revealed significant medium correlation between ASES and both LSA (r = -0.43, p = .001) and DSA (r = 0.39, p = .002). The DSA of patients with ASES > 76 was 48.55 ± 12.44 with an IQR of 39.5 – 57.5, as compared to lower values for patients with ASES < 76, which was 37.82 ± 9.8 (IQR 32 – 46.5) (p=0.009). Similarly, the LSA of patients with ASES > 76 was 86.43 ± 11.4 (IQR 79.5 – 93.5), as compared to higher values for patients with ASES < 76, which was 100.09 ± 7.63 (IQR 93 – 105.5) (p<0.001). The ROC curve confirmed LSA and DSA as good predictors for the ASES outcome, with AUCs of 0.851 and 0.741, respectively. The optimal LSA should be no more than 90.5° (Se=100%, Sp=67.7%). The optimal DSA should be no less than 37.5° (Se=78.4%, Sp=63.6%). ConclusionThe LSA and DSA angle could represent a helpful tool to optimize the clinical outcomes of an adaptable RTSA in CTA with a functional deltoid and a complete passive range of motion.

The Effect of Smoking on Outcomes of Reverse Total Shoulder Arthroplasty

BackgroundThe effect of smoking status on clinical outcomes in reverse total shoulder arthroplasty (rTSA) has not been thoroughly characterized. We sought to compare pain and functional outcomes, complications, and revision-free survivorship between current smokers, former smokers, and non-smokers undergoing primary rTSA. MethodsWe retrospectively reviewed a prospectively-collected shoulder arthroplasty database from 2004-2020 to identify patients who underwent primary rTSA. Three cohorts were created based on smoking status: current smokers, former smokers, and non-smokers. Outcome scores (SPADI, SST, ASES, UCLA, Constant), range of motion (ROM) (external rotation [ER], forward elevation [FE], abduction, internal rotation [IR]) and shoulder strength (ER, FE) evaluated at 2-4-year follow-up were compared between cohorts. The incidence of complication and revision-free implant survivorship were evaluated. ResultsWe included 676 primary rTSAs, including 38 current smokers (44±47 pack-years), 84 former smokers who quit on average 20±14 years (range: 0.5-57 years) prior to surgery (38±32 pack-years), and 544 non-smokers. At 2-4-year follow-up, current smokers had less favorable SPADI, SST, ASES scores, UCLA scores, and Constant scores compared to former smokers and non-smokers. On multivariable analysis, current smokers had less favorable SPADI, SST, ASES score, UCLA score, and Constant score compared to non-smokers. There were no significant differences between cohorts in complication rate and revision-free survivorship. ConclusionOur data showed that current smokers may have poorer functional outcomes after rTSA compared to former smokers and non-smokers despite the incidence of complications and revision surgery not differing significantly between cohorts.

Reverse Allograft Prosthetic-Composite Versus Endoprosthesis Reconstruction for Massive Proximal Humerus Bone Loss: A Systematic Review and Meta-analysis of Outcomes and Complications.

This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis. Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery. Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P = .231), external rotation (P = .634), ASES score (P = .420), Constant score (P = .414), MSTS (P = .815), SST (P = .367), or VAS (P = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate. Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience. Level IV; Systematic Review. The online version contains supplementary material available at 10.1007/s43465-024-01248-7.

Survivorship and Clinical Outcomes of Reverse Total Shoulder Arthroplasty in Patients with Large Glenoid Defects Using the Stilting Technique and a Baseplate with Central Ingrowth Cage and Peripheral Locking Screws

Stilting is a novel technique used in reverse shoulder arthroplasty (RSA) in patients with significant glenoid bone loss. This technique utilizes peripheral locking screws placed behind an unseated portion of the baseplate, to transmit forces from the baseplate to the cortical surface of the glenoid, without the need for bone grafting. The stilted screw, once locked, provides a fixed angle point of support for an unseated aspect of a baseplate. The primary advantages of this technique are reduced cost compared to a custom implant and reduced operative time compared to bone grafting. We conducted a retrospective, non-randomized, comparative cohort study of 41 patients underwent primary Reverse Shoulder Arthroplasty (RSA) using the Stilting Technique with the Exactech Equinoxe Reverse System (Gainesville, FL, USA) at a single, academic center from the years 2004-2021. Exclusion criteria included age under 18 or over 100, and oncologic or acute fracture RSA indications. Operative data was documented, including implant records, percent baseplate seating, and operative duration. Survivorship was compared among primary stilted-RSA (n=41), bone graft-RSA (n=42), and non-stilted/non-bone grafted RSA (n=1,032) within our institutional shoulder arthroplasty database. A radiographic examination of baseplate failure was also conducted across the study groups. Postoperative functional outcomes were compared in a matched analysis involving patients with a minimum 2-year follow-up between stilted patients and a non-stilted/non-bone grafted control group for primary RSA. All Stilted-RSA cases utilized metal augments and demonstrated a mean baseplate seating of 61% (range 45-75%). For stilted RSAs, survivorship was 100% and 92.6% at 2- and 5-years, compared to 98.3% and 94.6% for non-stilted/non-bone grafted and 96.3% and 79.5% for bone-grafted RSAs (p=0.042). At 5-years, the baseplate-related failure rates were greater in the stilted (7.4%) and the bone-grafted (9.3%) cohorts compared with the non-stilted/non-bone grafted cohort (1.1%, p<0.001). The mean time to baseplate failure was 30 months for stilted RSA. Functional outcomes for primary RSA were statistically similar between stilted and non-stilted patients, including range of motion, Constant, ASES, SST, UCLA, and SPADI scores. The stilted-RSA cohort exhibited noninferior revision and baseplate failure rates to that of bone-grafted RSA. This suggests that stilting may be a viable technique for patients undergoing primary RSA with significant glenoid deformity.

Open Latarjet reduces residual apprehension, redislocation and possibility of dislocation arthropathy compared to arthroscopic Bankart repair despite greater bipolar bone loss in anterior glenohumeral instability

BackgroundArthroscopic Bankart repair (ABR) and the open Latarjet (OL) procedure are the most frequently preferred methods in the treatment of anterior glenohumeral instability. The aim of this study was to compare patients who underwent ABR or OL due to anterior glenohumeral instability in terms of functional capacity, glenohumeral bone loss, residual apprehension, redislocation and dislocation arthropathy. MethodsA total of 56 patients who underwent ABR or OL due to anterior glenohumeral instability between January 2018 and December 2021 were evaluated retrospectively. There were 32 patients in the ABR group and 24 patients in the OL group. Patients’ demographic characteristics, number of preoperative dislocations, and return-to-work and follow-up periods were recorded. Glenoid bone loss, Hill-Sachs interval, and Hill-Sachs depth were measured from preoperative computed tomography sections. The ASES score, WOSI score, Rowe score, and joint range of motion were calculated. Patients were also asked about residual apprehension, postoperative redislocations, dislocation arthropathy and surgery satisfaction. ResultsThe mean age of the ABR group was 22.5±3.9 years (28 men, 4 women), while that of the OL group was 25.0±4.8 years (22 men, 2 women). The mean number of dislocations was 2.7±1.3 in the ABR and 10.9±5.5 in the OL (p=0.001). Higher values of glenoid bone loss (%) (ABR: 6±2; OL: 20±4), Hill-Sachs interval (mm) (ABR: 8±3; OL: 21±3), and Hill-Sachs depth (mm) (ABR: 5±2; OL: 8±2) were measured in the OL (p=0.001 for all), reflecting significantly more bone loss. Residual apprehension was detected in 10 patients in the ABR and 2 patients in the OL (p=0.007). While 4 patients in the ABR had a history of redislocation, no redislocation occurred in the OL (p=0.012). Dislocation arthropathy development was observed in 9 patients in the ABR and 4 patients in the OL (p=0.038) according to the modified Samilson and Prieto classification. External rotation in adduction and external rotation in 90° abduction were approximately 5° higher in the OL (p=0.011 and p=0.016, respectively). ConclusionThe ABR and OL methods both provide satisfactory outcomes in the treatment of anterior glenohumeral instability with appropriate indications. The OL procedure is preferred for patients with more dislocations and greater bipolar bone loss. Despite greater bipolar bone loss, the OL procedure provides lower rates of residual apprehension, redislocation and dislocation arthropathy. Additionally, due to the stability it provides, there is less loss in external rotation.

Clinical Outcomes After Mini-Open Subpectoral Biceps Tenodesis

Background Long head of the biceps tendon pathology is a common cause of shoulder pain. Current surgical treatment options for long head of the biceps tendon disorders include tenotomy and tenodesis. Younger and high-demand patients are usually treated with tenodesis since tenotomy is associated with increased biceps pain and cramping, cosmetic deformity and patient dissatisfaction. Previous studies have shown biomechanical advantages of subpectoral open approach over arthroscopic suprapectoral approach, with less biceps over tension and increased ultimate load to failure. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Methods We retrospectively reviewed all patients who underwent subpectoral biceps tenodesis with unicortical endo-button fixation between January 2015 and December 2019. Only patients who had a minimum of 24 months follow-up were included in the study. We reviewed patient demographics. The American Shoulder and Elbow Surgeons and Visual Analogue score were assessed and complications were recorded. Results A total of thirty-two patients were enrolled in this study. 15 were young patients and sports athletes with SLAP (Superior Labrum from Anterior to Posterior) lesions or isolated biceps instability and the remaining 17 were middle-age patients with degenerative biceps disease and concomitant pathology. The mean follow-up time was 36 months. SLAP lesions group average age was 24,3 and degenerative group average age was 53,8. The ASES score and the VAS score and were statically significative better in the isolated subpectoral tenodesis due to SLAP lesions 99,8 and 0,1 respectively in comparison with the degenerative group, 85,7 and 1,5 respectively. We recorded two complications. One case of superficial infection and one case of a patient that was concomitant submitted to arthroscopic rotator cuff tear repair with persisting shoulder pain. There was no case of failure of fixation or associated Popeye deformity. Conclusions Subpectoral biceps tenodesis with unicortical endo-button fixation is a viable treatment option for patients with symptomatic biceps disease. Anterior shoulder pain and biceps symptoms were resolved with this technique. Patients with coexistent rotator cuff lesion may have less favorable outcomes.

Superior Capsular Reconstruction Using an Acellular Dermal Xenograft or Allograft Improves Shoulder Function but Is Associated with a High Graft Failure Rate.

Objectives: The purpose of the present study was to evaluate clinical and functional outcomes, graft integrity rate and progression of osteoarthritis after superior capsular reconstruction (SCR) at short-term follow-up. Methods: Consecutive patients that underwent SCR using an acellular dermal xeno- or allograft between May 2018 and June 2020 for the treatment of irreparable posterosuperior rotator cuff tears were included. Shoulder function (American Shoulder and Elbow Surgeons [ASES] score), pain (Visual Analog Scale [VAS] for pain) and active shoulder range of motion (ROM) were evaluated preoperatively and after a minimum of 24 months postoperatively. Isometric strength was measured at follow-up and compared to the contralateral side. Magnetic resonance imaging was performed to evaluate graft integrity and osteoarthritis progression (shoulder osteoarthritis severity [SOAS] score). Results: Twenty-two patients that underwent SCR using a xeno- (n = 9) or allograft (n = 13) were evaluated 33.1 ± 7.2 months postoperatively. Four patients in the xenograft group underwent revision surgery due to pain and range of motion limitations and were excluded from further analysis (revision rate: 18.2%). Shoulder function (ASES score: 41.6 ± 18.8 to 72.9 ± 18.6, p < 0.001), pain levels (VAS for pain: 5.8 ± 2.5 to 1.8 ± 2.0, p < 0.001) and active flexion (p < 0.001) as well as abduction ROM (p < 0.001) improved significantly from pre- to postoperatively. Active external rotation ROM did not improve significantly (p = 0.924). Isometric flexion (p < 0.001), abduction (p < 0.001) and external rotation strength (p = 0.015) were significantly lower in the operated shoulder compared to the non-operated shoulder. Ten shoulders demonstrated a graft tear at the glenoid (n = 8, 44.4%) or humerus (n = 2, 11.1%). Graft lysis was observed in seven shoulders (38.9%). The graft was intact in one shoulder (5.6%), which was an allograft. A significant progression of shoulder osteoarthritis was observed at follow-up (SOAS score: 42.4 ± 10.1 to 54.6 ± 8.4, p < 0.001). Conclusions: At short-term follow-up, SCR using an acellular dermal xeno- or allograft resulted in improved shoulder function and pain with limitations in active external rotation ROM and isometric strength. Graft failure rates were high and osteoarthritis progressed significantly. Level of Evidence: Retrospective cohort study, Level III.

Improved patient reported outcomes with knotless double-row rotator cuff repair with and without lateral row biceps tenodesis at 2- and 5-years

BackgroundThe purpose of this study is to report outcomes of an arthroscopic knotless double-row (DR) rotator cuff repair (RCR) technique at 2- and 5- years postoperatively, and to compare clinical outcomes in patients undergoing knotless DR RCR with incorporated lateral row biceps tenodesis vs. those without lateral row biceps tenodesis. MethodsAll primary RCR surgeries were performed by a single surgeon at a single institution using a knotless transosseous equivalent (TOE) technique. The postoperative rehabilitation protocol was standardized for all patients. The primary outcomes collected included ASES Function, ASES Index, SANE, SST, VR-12 physical and mental, and VAS scores. ResultsThree hundred forty-two patients met inclusion criteria, of which 262 patients underwent isolated RCR and 61 underwent RCR with a concomitant lateral row biceps tenodesis, 15 underwent RCR with concomitant tenotomy and 4 had RCR with débridement of the biceps. Significant improvements in VAS, ASES, SANE, SST, and VR-12 scores were observed at all time points in all patient groups. No statistically significant differences in outcomes were noted in patients undergoing RCR with a lateral row tenodesis vs. those undergoing RCR alone. Similarly, no differences were seen when stratified by age, sex, BMI, Worker’s Compensation (WC) status, smoking, and diabetes mellitus (DM). Based on ASES, 81% of patients met minimum clinically important difference (MCID), and 64% met maximum outcome improvement (MOI) at 1-year postoperatively. ConclusionKnotless DR TOE arthroscopic RCR significantly improves patient-reported clinical outcomes at 1-, 2- and 5-year follow-ups. These results are reflected in clinical practice because 80% achieve MCID postoperatively. Patient-related factors, including BMI, age, sex, WC, and DM do not significantly affect patient-reported outcomes in the first 5 years after surgery. Smokers have worse baseline scores which persist at 2-year follow-up. Lastly, adding an arthroscopic lateral row biceps tenodesis in knotless DR TOE arthroscopic RCR provides similar clinical outcomes to knotless DR TOE arthroscopic RCR without biceps tenodesis.