Elbow Surgeons Score Research Articles

Delamination of rotator cuff tears impairs healing after repair: a systematic review and meta-analysis.

To compare the clinical outcomes and retear rates after rotator cuff repair (RCR) between delaminated and non-delaminated tears. This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines using the PubMed, Cochrane Library, the Web of Science and Embase databases. Only articles on arthroscopic RCR with clinical outcome scores and data on the number of rotator cuff retears and complete healing were included. This study's relevant data were extracted and statistically analyzed. The methodological index for nonrandomized studies was used to assess the risk of bias in the included studies. After conducting a heterogeneity test and sensitivity analysis to determine whether the samples were heterogeneous, the study also detected publication bias. A sub-group test was used to evaluate the influences of the imaging follow-up period on retear rates. Ten eligible articles were identified with 2,061 patients (925 in the delaminated group and 1,136 in the non-delaminated group). The meta-analysis demonstrated that delamination was significantly associated with higher retear rates (P = 0.026; odds ratio = 1.873, 95% confidence interval 1.079-3.252; I2 = 51.6%) with an imaging follow-up period of > 1year and lower rates of complete healing (P = 0.036; odds ratio = 0.659, 95% confidence interval 0.446-0.973; I2 = 9.0%) in patients after rotator cuff repair. However, no significant differences were observed between the two groups based on American Shoulder and Elbow Surgeons score, Constant score, visual analog scale score, external rotation, internal rotation, or forward elevation. This meta-analysis found that delamination was significantly associated with higher retear rates with imaging follow-up period of > 1year, and lower rates of complete healing. In addition, the preoperative and postoperative clinical scores and shoulder joint range of motion were similar between patients with delaminated and non-delaminated tears. Level IV.

Hemiarthroplasty for proximal humerus fractures: clinical and radiographic outcomes after an average of 19 years

BackgroundThe main objective of this retrospective analysis was to report on the long-term clinical and radiographic outcomes (>10 years) in a series of patients who have previously undergone hemiarthroplasty for proximal humerus fracture. Materials and methodsThe charts of 11 patients (12 shoulders) who underwent hemiarthroplasty for proximal humerus fractures were retrospectively analyzed and stratified based on tuberosity healed (TH) or tuberosity resorption (TR). The primary end points included range of motion measurements and patient-reported outcome scores. We obtained forward elevation, exterx nal rotation, internal rotation, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and Visual Analog Scale (VAS) scores. Tuberosity healing or resorption, acromiohumeral interval, subluxation, and humeral radiolucency were analyzed separately by 2 fellowship-trained orthopedic surgeons. ResultsThe mean age at surgery for TH patients was 60.0 ± 9.8 years and for TR patients was 57.7 ± 4.3 years. There were 7 cases in tuberosity healing cohort and 5 cases in the tuberosity resorption cohort. Implant survivorship at final follow-up was 100% (7/7) for TH and 60% (3/5) for TR; 2 patients who failed hemiarthroplasty were converted to reverse total shoulder arthroplasty. Mean postoperative forward elevation (TH: 155°, TR: 36°; P value < .01), external rotation (TH: 59°, TR: 28°; P value < .01), and internal rotation (TH:T12, TR:L3; P value = .08) were higher in the TH cohort. American Shoulder and Elbow Surgeons scores (TH: 90, TR: 40; P value < .01) and Simple Shoulder Test scores (TH: 9, TR: 2; P value < .01) were statistically significant between the 2 cohorts while VAS scores approached significance (mean VAS [TH: 1, TR: 4; P value = .08]). DiscussionTo our knowledge, this study provides the longest follow-up to date for outcomes following hemiarthroplasty with fracture. Significant improvements in shoulder function and reduction in pain levels are sustainable even after 19 years in patients whose tuberosity heals. Hemiarthroplasty remains a viable option for younger candidates whose tuberosity will heal postoperatively.

Improved functional, radiographic and patient-reported outcomes at midterm follow-up for shoulder arthroplasty patients 75 years and older

BackgroundCurrent discussion centers around the appropriateness of shoulder arthroplasty in elderly patients, and whether anatomic and reverse total shoulder arthroplasty yield acceptable results in this population. The purpose of this study was to examine midterm outcomes in patients 75 years and older who underwent either procedure. MethodsA retrospective review was performed on patients who underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) between 2000 and 2018. Inclusion criteria was patient age ≥75 years at time of surgery and ≥1 years postoperative follow-up. Primary outcomes were differences in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, and range of motion. A secondary outcome was revision surgery. Results22 patients who underwent aTSA and 17 patients who underwent rTSA were included. Mean age at surgery was 79 and 80 in the aTSA and rTSA groups, respectively. Mean postoperative follow-up was 6.6 years across both cohorts. Anatomic TSA patients experienced improvements in VAS (7 preop vs. 1 postop; p < 0.001), ASES (16 vs. 75; p < 0.001), and SST (2 vs. 8; p < 0.001) scores. Reverse TSA patients also experienced improvements in VAS (7 vs. 1; p < 0.001), ASES (29 vs. 74; p < 0.001), and SST (1 vs. 7; p < 0.001) scores. Anatomic TSA patients experienced improved external rotation (17° vs. 53°; p < 0.001), forward elevation (108° vs. 155°; p < 0.001), and internal rotation (L5 vs. T10; p < 0.001). Reverse TSA patients experienced improved forward elevation (52° vs. 126°; p < 0.001). 21 aTSA patients (100%) and 16 rTSA patients (94%) experienced survival free from revision. 100% of aTSA and rTSA patients experienced survival free from loosening. ConclusionBoth aTSA and rTSA can be performed in the elderly population with acceptable midterm outcomes, suggesting that implant survival and patient satisfaction have the potential to endure through the end of life. Level of evidenceIV.

Greater Socioeconomic Disadvantage as Measured by the Area Deprivation Index Is Associated With Failure of Healing Following Arthroscopic Repair of Massive Rotator Cuff Tears but Not With Clinical Outcomes

To analyze the relationship between Area Deprivation Index (ADI) and preoperative status and short-term postoperative clinical outcomes among patients who underwent arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCTs). A retrospective review was conducted on prospectively maintained data on patients who underwent ARCR of MRCTs defined as tear size ≥5 cm or complete tear of at least 2 tendons, with a minimum 2-year follow-up and a valid home address between January 2015 and December 2018. Each patient's home address was mapped to the ADI to determine neighborhood disadvantage. This composite index is composed of 17 census-based indicators, including income, education, employment, and housing quality to quantify the level of socioeconomic deprivation. Ratings were recorded and categorized based on the sample's percentile. Patients were then divided into 2 groups: upper quartile (ie, most disadvantaged [≥75th percentile]) and lower 3 quartiles (ie, least disadvantaged [<75th percentile]). Bivariate analysis was performed to associate ADI with patient-reported outcomes (PROs) and range of motion pre- and postoperatively, as well as complications, healing rate, satisfaction, and return to work. Patients reaching or exceeding the minimal clinically important difference for visual analog scale (VAS), American Shoulder and Elbow Surgeons, Veterans Rand 12-Item questionnaire, and subjective shoulder value were recorded for both cohorts. Ninety-nine patients were eligible for study analysis. Preoperative PROs and range of motion were similar, except for a greater VAS for pain (6.3 vs 4.3; P < .01) and lower American Shoulder and Elbow Surgeons score (32.2 vs 45.1; P= .01) in the most disadvantaged group. Both groups showed similar postoperative PROs scores, but greater VAS improvement was seen in the upper quartile group (Δ 4.2 vs Δ 3.0; P= .04). In contrast, only the least-disadvantaged group significantly improved in internal rotation (P= .01) and forward flexion (18°; P < .01) from baseline. Although satisfaction, complications, and return to work were comparable (P > .05), failure of healing occurred more frequently in the most disadvantaged group (21% vs 6%; P= .03). Patients with MRCTs residing in the most disadvantaged neighborhoods as measured by the ADI have more pain and functional limitations before undergoing ARCR but demonstrate similar postoperative functional improvements to patients from other socioeconomic backgrounds. Failure of healing of MRCTs may be more common in disadvantaged groups. Furthermore, both groups reported similar rates of clinically important functional improvement. Level III, retrospective cohort comparison.

Comparison of 1- and 3-Week Immobilization Following Arthroscopic Shoulder Stabilization: Results of a Prospective Study

Purpose: We investigated the effects of 1- and 3-week of absolute immobilization duration on pain, range of motion (ROM), shoulder function, and recurrence rate on shoulder arthroscopic anterior capsulolabral repair (AACR) patients. Method: Fifty shoulder AACR patients’ pain intensity, shoulder ROM, and function were evaluated 4, 8, and 12 weeks after surgery (1-week group: 26; 3-week group: 24 patients). Function was assessed with American Shoulder and Elbow Surgeons (ASES) score at postoperative 12 weeks and final follow-up (average of postoperative 30 months). Whether there was a re-dislocation after surgery was also questioned at final follow-up. Results: Similar ROM were observed on both groups at the postoperative 4, 8, and 12 weeks ( p &gt; 0.05). Pain intensities at rest ( p = 0.40), night ( p = 0.22), and during the activity ( p = 0.49) were also similar on both groups. Also, no difference was observed for function between the two groups ( p = 0.99). Only one re-dislocation was in the 3-week immobilization group. Conclusion: Both 1- and 3-week of absolute immobilization demonstrated similar results in terms of shoulder ROM, pain, function, and recurrence rate after the shoulder AACR. Furthermore, earlier mobilization led to higher shoulder flexion at 4 weeks postoperatively. Either of the rehabilitation approaches can be adopted based on the patient's situation.

Risk factors for intracellular fatty accumulation in rotator cuff muscle: a histologic analysis

Fatty accumulation in rotator cuff muscles has been associated with shoulder dysfunction, risk of repair failure, and poor postoperative outcomes. This study sought to assess risk factors associated with true fatty accumulation based on histologic analysis and determine whether preoperative function directly correlated with this fatty rotator cuff accumulation. Supraspinatus muscle biopsy specimens obtained prospectively from patients undergoing arthroscopic rotator cuff repair were stained with LipidTOX to quantify lipid accumulation. Two-step cluster analysis with Goutallier classification was used to define the fatty and non-fatty rotator cuff groups. We further performed a receiver operating characteristic curve analysis to confirm the group cutoff values. In total, 51 patients (aged 60.1±10.5 years) were included. There were 19 high-grade partial tears, 10 small tears, 7 medium tears, 10 large tears, and 5 massive tears. Both cluster and receiver operating characteristic curve analyses yielded a cutoff value of 30% LipidTOX/4',6-diamidino-2-phenylindole (DAPI) separating the fatty vs. non-fatty groups. In the univariate analysis, patients with fatty rotator cuffs were aged 63.2 years on average compared with 59.7 years in the non-fatty group (P=.038). Female patients made up 57.1% of the fatty cohort, which was statistically higher than the non-fatty group (P=.042). Massive and large tears were more likely to occur in the fatty group (P=.005). In the multivariate analysis, full tendon tears had the largest predictive status of falling into the fatty group (odds ratio, 15.4; P=.008), followed by female sex (odds ratio, 4.9; P=.036). Patients in the fatty group had significantly higher American Shoulder and Elbow Surgeons scores (P=.048) and lower visual analog scale scores (P=.002). This prospective histologic assessment revealed that full-thickness rotator cuff tears and female sex were the largest risk factors for intracellular lipid accumulation. Although tear size correlated with fatty accumulation, the sex disparity is a noteworthy finding that warrants further research.

Mild Biceps Tendonitis May Be Managed Nonoperatively During Shoulder Arthroscopy

The purposes of this study were to determine whether patients with mild biceps tendonitis required revision surgery after the biceps tendon was not surgically treated, while addressing concomitant pathology, and to evaluate whether preoperative groove pain affected patient-reported outcomes. Patients who underwent shoulder arthroscopy between 2015 and 2018 by a single surgeon for rotator cuff pathology, debridement, and distal clavicular excision (DCE), with or without subacromial decompression (SAD), and where the biceps tendon was not surgically addressed were retrospectively identified. Inclusion criteria were mild LS (<50% hyperemic appearing biceps tendon arthroscopically), and a minimum 2-year follow-up. The primary outcome measure was the incidence of revision surgery. Secondary outcomes included American Shoulder and Elbow Surgeons (ASES) score, simple shoulder test (SST), pain level, and satisfaction scores. Two sample t-tests compared postoperative patient-reported outcomes based on the presence or absence of preoperative bicipital groove tenderness. Sixty-four of 69 eligible subjects (93%) were evaluated at a minimum of 2 years postoperatively. One out of 64 subjects underwent revision to perform a biceps tenodesis. Overall, patients had high patient-reported outcome measures (PROMs) postoperatively. Ninety-seven percent of patients reported they would have the surgery again. The presence of preoperative bicipital groove tenderness had no effect on ASES (P= .62), SST (P= .83) scores, and postoperative pain (P= .65). Patients without bicipital groove pain had average respective ASES and SST scores of 93.70 ± 11.84 and 10.66 ± 2.47; those with bicipital groove pain averaged 92.00 ± 15.31 and 10.78 ± 1.87. There was no significant difference in overall satisfaction scores between patients with groove pain (9.42 ± 1.40) and those without (9.46 ± 1.38; P= .92). Patients with mild biceps tendonitis showed favorable outcomes with low revision rates and high patient satisfaction when the biceps tendon was not surgically addressed when the primary shoulder pathology was treated during arthroscopy, independent of preoperative groove pain. Level III, retrospective cohort study.

Revision Subpectoral Biceps Tenodesis Demonstrates a High Patient Satisfaction and Good Functional Outcomes

To clinically evaluate a subset of patients who underwent a revision subpectoral biceps tenodesis for a clinically failed proximal biceps tenodesis. This is a retrospective case series of patients with at least 2-year follow-up who had undergone a revision biceps tenodesis after clinical failure of a proximal biceps tenodesis between January 2008 and February 2020 by a single surgeon. Patients who underwent concomitant procedures, such as revision cuff repair, were excluded. Patients with a minimum of 2 years duration status postrevision subpectoral tenodesis were contacted for informed consent and outcome data, which included Simple Shoulder Test, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective reporting of arm weakness and satisfaction. Fourteen patients were initially identified as meeting inclusion criteria with a minimum 2-year follow-up achieved for 11 of 14patients (78.5% follow-up). The mean follow-up time was 8.1 years (range, 2.7-14.8 years). After the primary biceps tenodesis, a mean of 8.0 ± 9.6 months passed before the revision subpectoral biceps tenodesis was performed. The average postoperative active forward elevation and adducted external rotation were 159 ± 7° and 47 ± 17°, respectively. The mean ± standard deviation (range) follow-up American Shoulder and Elbow Surgeons score was 79 ± 23 (30-100), Simple Shoulder Test was 11 ± 2 (7-12), and visual analog scale for pain was 2.6 ± 2.8 (0-9). All 11 patients reported being satisfied with their operation and would elect to have the operation again. Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis. Although some persistent pain is common, revision subpectoral biceps tenodesis demonstrates a high patient satisfaction and good functional outcomes. Level IV, therapeutic case series.

Establishing the Minimal Clinically Important Difference and Patient Acceptable Symptom State Thresholds Following Arthroscopic Capsular Release for the Treatment of Idiopathic Shoulder Adhesive Capsulitis

PurposeTo determine the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS) threshold for the visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE), and American Shoulder and Elbow Surgeons (ASES) scores following arthroscopic capsular release for the treatment of idiopathic shoulder adhesive capsulitis. MethodsA retrospective review of prospective collected data was performed in patients undergoing arthroscopic capsular release for the treatment of idiopathic adhesive capsulitis at a single institution from January 2018 through January 2019. Patient-reported outcome measures were collected preoperatively and 6 months’ postoperatively. Delta was defined as the change between preoperative and 6 months’ postoperative scores. Distribution-based and anchored-based (response to a satisfaction question at 1 year) approaches were used to estimate MCIDs and PASS, respectively. The optimal cut-off point where sensitivity and specificity were maximized (Youden index) and the percentage of patients achieving those thresholds were also calculated. ResultsOverall, a total of 100 patients without diabetes who underwent arthroscopic capsular release and completed baseline and 6-month patient-reported outcome measures were included. The distribution-based MCID for VAS, Constant, SANE, and ASES were calculated to be 1.1, 10.1, 9.3, and 8.2, respectively. The rate of patients who achieved MCID thresholds was 98% for VAS, 96% for Constant, 98% for SANE, and 99% for ASES. The PASS threshold values for VAS, Constant, and ASES were ≤2, ≥70, ≥80, and ≥80, respectively. The rate of patients who achieved PASS thresholds was 84% for VAS, 84% for Constant, 89% for SANE, and 78% for ASES. ConclusionsIn patients without diabetes and idiopathic adhesive capsulitis, high rates of MCID and PASS thresholds can be achieved with arthroscopic anteroinferior capsular release Level of EvidenceLevel IV, retrospective cohort study.

Rotator cuff preserving reverse shoulder arthroplasty vs. eccentrically reamed anatomic total shoulder arthroplasty for glenohumeral osteoarthritis and an intact rotator cuff with B2 glenoid deformity

BackgroundAnatomic total shoulder arthroplasty (TSA) is a common treatment choice for patients with advanced glenohumeral osteoarthritis and an intact rotator cuff. In the setting of B2 glenoid deformity, eccentric glenoid reaming with a TSA is a viable option; however, an increasing trend is to perform a reverse shoulder arthroplasty (RSA). The ideal implant choice for these patients is still uncertain. MethodsA retrospective review of an eccentrically reamed TSA (ER-TSA) cohort vs. a rotator cuff–preserving RSA (RCP-RSA) cohort performed from 2013 to 2021 was completed. Any patient with evidence of a B2 glenoid verified by preoperative computed tomography or magnetic resonance imaging was considered for inclusion. A retrospective review of patients’ last clinical follow-up was performed and radiographic review of postoperative complications. All patients were then contacted by phone to determine if they underwent any revision surgery and to obtain American Shoulder and Elbow Surgeons (ASES) scores. ResultsIn the ER-TSA cohort, 18 patients were identified and contacted for follow-up ASES questionnaire. The average age was 72. The average follow-up was 4.7 years, with an average clinic follow-up period of 15 months. The delta range of motion (ROM) for forward flexion was +35° improvement, for abduction was +17°, and for external rotation was +23°. The average ASES score was 87. For the RCP-RSA cohort, 17 patients were identified and contacted for ASES questionnaire with 19 total shoulders. The average age was 75. The average follow-up was 2.5 years, with an average clinic follow-up period of 18 months. The delta ROM for forward flexion was +53° improvement, for abduction was +61°, and for external rotation was +23°. The average ASES score was 93. ConclusionIn the present cohorts of ER-TSA vs. RCP-RSA for glenohumeral osteoarthritis with an intact rotator cuff and B2 glenoid deformity in patients 65+ years old, there were no revisions, and overall patients reported an ASES score of 87 for ER-TSA and 93 for RCP-RSA. This study demonstrates that both ER-TSA and RCP-RSA remain a viable option, however it also shows that RCP-RSA has better early to midterm patient-reported outcome measures, the ability to account for worse posterior glenoid deformity, and has greater overall improvement in ROM in such a commonly encountered patient population.

Application of Machine Learning Algorithms for Prognostic Assessment in Rotator Cuff Pathologies: A Clinical Data-Based Approach.

The overall aim of this proposal is to ameliorate the care of rotator cuff (RC) tear patients by applying an innovative machine learning approach for outcome prediction after arthroscopic repair. We applied state-of-the-art machine learning algorithms to evaluate the best predictors of the outcome, and 100 RC patients were evaluated at baseline (T0), after 1 month (T1), 3 months (T2), 6 months (T3), and 1 year (T4) from surgical intervention. The outcome measure was the Costant-Murley Shoulder Score, whereas age, sex, BMI, the 36-Item Short-Form Survey, the Simple Shoulder Test, the Hospital Anxiety and Depression Scale, the American Shoulder and Elbow Surgeons Score, the Oxford Shoulder Score, and the Shoulder Pain and Disability Index were considered as predictive factors. Support vector machine (SVM), k-nearest neighbors (k-NN), naïve Bayes (NB), and random forest (RF) algorithms were employed. Across all sessions, the classifiers demonstrated suboptimal performance when using both the complete and shrunken sets of features. Specifically, the logistic regression (LR) classifier achieved a mean accuracy of 46.5% ± 6%, while the random forest (RF) classifier achieved 51.25% ± 4%. For the shrunken set of features, LR obtained a mean accuracy of 48.5% ± 6%, and RF achieved 45.5% ± 4.5%. No statistical differences were found when comparing the performance metrics of ML algorithms. This study underlines the importance of extending the application of AI methods to new predictors, such as neuroimaging and kinematic data, in order to better record significant shifts in RC patients' prognosis. The data quality within the cohort could represent a limitation, since certain variables, such as smoking, diabetes, and work injury, are known to have an impact on the outcome.

Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the 1st TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. We performed a retrospective review of a prospectively-collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons (ASES) score for the 1st TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (30%MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after 2nd contralateral TSA, we performed multivariable logistic regression adjusted for age at 2nd surgery, sex, BMI, and type of 1st and 2nd TSA. Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after 1st TSA was not associated with greater odds of achieving thresholds after 2nd TSA when success was evaluated by the MCID, SCB, and 30%MPI. In contrast, exceeding the PASS after 1st TSA was associated with 5.9-times greater odds (95% CI = 2.5-14.4, P<0.001) of exceeding the PASS after 2nd TSA. Overall, patients that exceeded the PASS after 1st TSA exceeded the PASS after 2nd TSA at a higher rate (71% vs. 29%, P<0.001); this difference persisted when stratified by type of prosthesis for 1st and 2nd TSA. Patients that achieve the ASES score PASS after 1st TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Patients that have intraoperative deviations in their preoperative plan have inferior clinical and radiographic outcomes after anatomic total shoulder arthroplasty.

Three-dimensional, computed tomography, preoperative planning has become adopted among shoulder arthroplasty surgeons. Prior studies have not examined outcomes in patients in which the surgeon implanted prostheses that deviated from the preoperative plan compared to patients in which the surgeon followed the preoperative plan. The hypothesis of this study was that clinical and radiographic outcomes would be equivalent between patients undergoing anatomic total shoulder arthroplasty that had a deviation in the components predicted in the preoperative plan compared to patients that did not have a change in the components predicted in the preoperative plan. A retrospective review of patients that had preoperative planning for anatomic total shoulder arthroplasty from March 2017 thru October 2022 was performed. Patients were stratified into two groups: patients in which the surgeon utilized components that deviated from those anticipated by the preoperative plan (changed group), and patients in which the surgeon utilized all of the components anticipated by the preoperative plan (planned group). Patient-determined outcomes including the Western Ontario Osteoarthritis Index (WOOS), American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Shoulder Activity Level (SAL) were recorded preoperatively, at one-year, and at two-years. Preoperative and one-year postoperative range-of-motion was recorded. Radiographic parameters to assess restoration of proximal humeral anatomy included humeral head height, humeral neck angle, humeral centering on the glenoid, and postoperative restoration of the anatomic center of rotation. One-hundred-and-fifty-nine patients had intraoperative changes to their preoperative plan and 136 patients underwent arthroplasty without changes to their preoperative plan. The planned group had higher scores compared to the group that had a deviation in the preoperative plan for every patient-determined outcome metric at every postoperative timepoint with statistically significant improvements found in the SST and SANE at one-year and SST and ASES at two-year follow-up. No differences were found in range of motion metrics between groups. Patients that did not have a deviation in their preoperative plan had more optimal restoration of their postoperative radiographic center of rotation compared to patients that did have a deviation in their preoperative plan. Patients that have intraoperative changes to their preoperative plan have 1) inferior postoperative patient determined outcome scores at one and two years after surgery and 2) a larger deviation in the postoperative radiographic restoration of the humeral center of rotation compared to patients that did not have intraoperative changes from the initial plan.

Subacromial notching after reverse total shoulder arthroplasty.

Scapular notching is a well-known postoperative complication of reverse total shoulder arthroplasty (RTSA). However, subacromial notching (SaN), a subacromial erosion caused by repeated abduction impingement after RTSA, has not been previously reported in a clinical setting. Therefore, this study aimed to assess the risk factors and functional outcomes of SaN after RTSA. We retrospectively reviewed the medical records of 125 patients who underwent RTSA with the same design between March 2014 and May 2017 and had at least 2 years of follow-up. SaN was defined as subacromial erosion observed at the final follow-up but not on the X-ray 3 months after surgery. Radiologic parameters representing the patient's native anatomy and degrees of lateralization and/or distalization during surgery were evaluated using preoperative and 3 months postoperative X-rays. The visual analogue scale of pain, active range of motion, and American Shoulder and Elbow Surgeons score were assessed preoperatively and at the final follow-up to evaluate the functional outcomes of SaN. SaN occurred in 12.8% (16/125) of enrolled patients during the study period. Preoperative center of rotation-acromion distance (P=.009) and postoperative humerus lateralization offset, which evaluated the degree of lateralization after RTSA (P=.003), were risk factors for SaN. The preoperative center of rotation-acromion distance and postoperative humerus lateralization cutoff values were 14.0mm and 19.0mm, respectively. The visual analogue scale of pain (P=.01) and American Shoulder and Elbow Surgeons score (P=.04) at the final follow-up were significantly worse in patients with SaN. SaN might adversely affect postoperative clinical outcomes. As SaN correlated with patients' anatomical characteristics and degree of lateralization during RTSA, the implant's degree of lateralization should be adjusted according to the patient's own anatomical characteristics.

Single knotless-anchor with two ethicon 2# for Ellman grade III bursal-side partial thickness rotator cuff tears: a cadaveric biomechanical study and short-term clinical evaluation

BackgroundSeveral surgical techniques are used to treat bursal-side partial thickness rotator cuff tears (PTRCTs). However, use of single knotless-anchor with two Ethicon 2# repair technique for PTRCTs has not been reported.Materials and methodsBursal-side PTRCTs (Ellman grade III, 75% thickness of tears) were created in the supraspinatus tendon in 16 fresh-frozen cadaveric shoulders. The specimens were randomly assigned to two equal groups: (1) Group A (Transtendon repair), a single knotless-anchor repair with two Ethicon 2#; (2) Group B, Conversion repair (Double-row, DR). Post-repair, each specimen was subjected to cyclic loading test from 5 to 100 N (50 cycles), followed by an ultimate failure test. The displacement of greater tuberosity (mm) and ultimate (N) were recorded. In the clinical study, 12 patients diagnosed with Ellman grade III Bursal-side PTRCTs (using a single knotless anchor with two Ethicon 2# repair techniques) were operated on and analyzed. Visual analog scale (VAS), American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion (ROM) were assessed before surgery and at final minimum follow-up (>1year).ResultsThere was no significant between-group difference with respect to load-to-failure test (Group A, 359.25 ± 17.91 N; Group B, 374.38 ± 13.75 N, P > 0.05). There were no significant differences with respect to rotator cuff displacement of 10 mm (Group A, 190.50 ± 8.52 N; Group B, 197.25 ± 6.84 N, P > 0.05) and 15 mm (Group A, 282.25 ± 12.20 N; Group B, 291.13 ± 14.74 N, P > 0.05). However, there was significant between-group difference with respect to displacement of 3 and 5 mm (P < 0.05). In the clinical trial, all patients were followed up for an average of 20.4 months (12–29 months). At the last follow-up after surgery(minimum>1year), the VAS score was 0.50 ± 0.67 (0–2), the ASES score was 86.50 ± 3.96 (79–92), the CMS score was 85.08 ± 5.65 (74–93), the mean Forward flexion ROM was 154.00°± 12.48° (131°-169°), and the abduction ROM was 165.00°±13.26° (138°-173°). There was a statistically significant difference between the results of the preoperative and the last postoperative follow-up. The results of the last postoperative follow-up were statistically different from those of the preoperative follow-up (P < 0.05). Regarding complications, stiffness (2 cases) and shoulder impingement (1 case) occurred in 3 cases (25%).ConclusionA single knotless anchor with two Ethicon 2# may provide a biomechanically and clinically feasible option for the treatment of bursal-side Ellman grade III PTRCTs, particularly in resource-constrained settings.MeSH keywordsBursal-side Ellman Grade III; Single Knotless-anchor; Double-row repair; Biomechanical study; Short-term clinical evaluation.

The influence of obesity on the complications and outcomes of shoulder arthroplasty: A systematic review and meta-analysis.

This systematic review aimed to determine whether obesity has a negative impact on the incidence of complications and functional scores of all types of shoulder arthroplasty. Electronic databases such as PubMed, Embase, Web of Science, and Cochrane were systematically searched for publications concerning obesity and shoulder arthroplasty. The Newcastle-Ottawa scale criteria were used to evaluate the study's quality. A total of 15 studies were identified involving total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty. The studies com- paring the outcome of shoulder arthroplasty in different weight groups were conducted after the search of related literature and grouped according to different weights and compared with each other. Counted data used odds ratio value and its 95% CI for data analysis, and measurement data used weighted mean difference and its 95% CI for statistical analysis. The remaining 12 articles met the inclusion criteria and were included in this review. Any infection was reported in 6 studies, including 197 013 patients. Infections were more likely to occur in obese patients, with an odds ratio of 3.38 (95% CI, 2.28-5.02). The operation time of overweight patients (body mass index >25 kg/m2) was significantly longer than that of normal-weight patients (odds ratio, 6.90; 95% CI, 3.79-10.00). The venous thromboembolism was more likely to occur in obese patients (odds ratio, 3.39; 95% CI, 3.6- 4.28). In addition, there was no significant difference in the dislocation rate and revision rate of prostheses among the groups. Patients who undergo shoulder arthroplasty could obtain a good American Shoulder and Elbow Surgeons score (Mean Difference [MD], 1.87; 95% CI, -2.08 to 5.82), regardless of their body mass index. Obesity had a negative impact on the prognosis of patients treated with shoulder arthroplasty. Additionally, obese patients require longer surgical times than normal-weight patients, although all patients can attain positive functional outcomes. Level III, Therapeutic Study.

Arthroscopic Scapulothoracic Bursectomy with and without Superomedial Angle Scapuloplasty: A Comparison of Patient-Reported Outcomes.

Operative treatment of scapulothoracic bursitis most commonly comprises arthroscopic scapulothoracic bursectomy with or without partial superomedial angle scapuloplasty. There is currently no consensus regarding if or when scapuloplasty should be performed. Prior studies are limited to small case series and optimal surgical indications are not yet established. The purposes of this study are to 1) retrospectively review patient reported outcomes of arthroscopic treatment of scapulothoracic bursitis and, 2) compare outcomes between scapulothoracic bursectomy alone and bursectomy with scapuloplasty. The authors hypothesized that bursectomy with scapuloplasty would provide superior pain relief and functional improvement. All cases of scapulothoracic débridement with or without scapuloplasty completed at a single academic center from 2007 through 2020 were reviewed. Patient demographics, symptomatology, physical exam findings, and corticosteroid injection response data were collected from the electronic medical record. Visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST), and SANE scores were collected. Comparisons between bursectomy alone and bursectomy with scapuloplasty groups were made using Student's t-test for continuous variables and Fisher's exact test for categorical variables. Thirty patients underwent scapulothoracic bursectomy alone, and 38 patients underwent bursectomy with scapuloplasty. Final follow-up data was completed for 56 of 68 (82%) cases. Final postoperative VAS pain scores (3.4±2.2 vs. 2.8±2.2 (p=0.351)), ASES scores (75.8±17.7 vs. 76.5±22.5 (p=0.895)), and SST scores (8.8±2.3 vs. 9.5±2.8 (p=0.340)) were similar between the bursectomy only and bursectomy with scapuloplasty groups, respectively. Both arthroscopic scapulothoracic bursectomy and bursectomy with scapuloplasty are effective treatments for scapulothoracic bursitis. Operative time is shorter without scapuloplasty. In this retrospective series, these procedures have similar outcomes regarding shoulder function, pain, surgical complications, and rates of subsequent shoulder surgery. Further studies with a focus in 3D scapular morphology may help optimize patient selection for each of these procedures.

Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes

Although short-term results are promising, there are limited data for long-term results of arthroscopic SSC repair. The purpose of this study is to report minimum ten-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the subscapularis (SSC) tendon. Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between 11/2005 and 8/2011. Patient reported outcome (PRO) measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. PROs utilized included the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS), return to activity, and patient satisfaction. A sub-analysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded. In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The ASES score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (p<.001). Regarding the SANE and QuickDASH Scores, only postoperative data was available. Mean postoperative SANE, QuickDASH, and SF-12 PCS scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sport. There was no correlation between patient age and clinical outcome (p>.05). No patients underwent revision surgery for a SSC retear. Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.

Intraoperative navigation system use increases accuracy of glenoid component inclination but not functional outcomes in reverse total shoulder arthroplasty: a prospective comparative study.

While the use of computer-assisted navigation systems in prosthetic implantation is steadily increasing, its utility in reverse shoulder arthroplasty (RSA) remains unclear. The purpose of this study was to evaluate the clinical utility of an intraoperative navigation system in patients undergoing RSA. Patients undergoing navigated or standard RSA at a single institution between September 2020 and December 2021 were prospectively enrolled. Exclusion criteria included noncompliance with study procedures or humeral fracture. Outcome measures included postoperative version and inclination, range of motion (ROM), complications, and patient-reported outcome measurements (PROMs: American Shoulder and Elbow Surgeons score [ASES], Disabilities of the Arm, Shoulder, and Hand score [DASH], Simple Shoulder Test [SST], and Visual Analog Scale [VAS]) at final follow-up. The final cohort contained 16 patients with navigation and 17 with standard RSA at a mean follow-up of 16months (range 12-18months). Average age was 72years (range 66-80years), 8 male (24%) and 25 female (76%). There were no differences in demographics between groups (p > 0.05). At baseline, the navigated group had a greater proportion of Walch B1 and B2 glenoids (p = 0.04). There were no differences between groups regarding baseplate type and native/planned/postoperative glenoid version and inclination. In both groups, planned and postoperative versions were not significantly different (p = 0.76). Patients who did not have navigation demonstrated significant differences between planned and postoperative inclination (p = 0.04), while those with navigation did not (p = 0.09). PROM scores did not differ between groups at final follow-up for SST (p = 0.64), DASH (p = 0.38), ASES (p = 0.77), or VAS (p = 0.1). No difference in final ROM was found between groups (p > 0.05). Over 50% of all screws in both groups were positioned outside the second cortex (p = 0.37), albeit with no complications. There were no statistically significant differences in ROM, PROMs, and satisfaction between patients receiving computer-navigated and standard RSA at a short-term follow-up. Despite more severe preoperative glenoid erosion in the navigated group, all patients were able to achieve an appropriate neutral axis postoperatively. The cost effectiveness and appropriate use of computer-navigated RSA warrant specific investigation in future studies. II, prospective cohort study. 9/1/2020 to 12/31/2021.

The effect of subscapularis repair in reverse total shoulder arthroplasty depends on the design of the implant: a comparative study with a minimum 2-year follow-up.

The role of the subscapularis (Ssc) tendon does not yet have a well-defined role in RSA. The purpose of the present study was to evaluate if the repair of the Ssc in RSA improves overall clinical and radiographic results and if it has the same results using a medialized design humeral stem compared to a lateralized design. Eighty-four consecutive patients undergoing RSA were retrospectively analyzed. Nine patients were lost at FU. Two implants with similar glenosphere design and different stem design (medialized and lateralized) were used. The Ssc was repaired in case of good quality of the fibers and reducibility without tension intraoperatively. Patients were divided into four groups for data analysis depending on whether they had received a medialized or lateralized design and Ssc repair or not. Patients were reviewed at an average follow-up of 40.8 ± 13.1months. Clinical outcome measures included Active range of motion (ROM), strength, visual analog scale (VAS), Constant-Murley score (CMS), and the American Shoulder and Elbow Surgeons score (ASES). Radiographic evaluation at final follow-up was performed to assess scapular notching, stress shielding, and radiolucent lines. No statistically significant clinical differences (p > 0.05) emerged between Lat/Ssc+ and Lat/Ssc-. Conversely, the patients belonging to the Med/Ssc- group reported statistically worse (p < 0.05) results than the Med/Ssc + group in terms of VAS, ASES and CMS. Statistically worse (p < .05) results in the Med/Ssc- group than in the Med/Ssc + were found also in active ROM achieved in FE, ABD, ER1 and ER2, and in the strength obtained in FE, ABD and ER2. Scapular notching was reported in 3 shoulders (15.7%) in Lat/Ssc+ group and in 7 shoulders (50%) in Lat/Ssc- group, while it was reported in 4 shoulders (14.2%) in Med/Ssc + group and in 6 shoulders (42.8%) in Med/Ssc- group. Stress shielding was observed in 6 cases in Lat/Ssc+ group (31.6%), in 8 cases in Lat/Ssc- group (57.1%), in 3 cases (10.7%) in Med/Ssc + group and 4 cases in Med/Ssc- group (28.6%). Patients undergoing RSA show clinical improvements at mid-term follow-up with a low rate of complications, regardless of the use of a medialized or a lateralized humeral stem design. Ssc repair is associated with better functional outcomes in the cohort of medialized stem, while it did not yield significant differences in the cohort of lateralized stem. Level III; Retrospective Cohort Comparison; Treatment Study.