Elbow Surgeons Standardized Shoulder Assessment Research Articles

Early results of reverse total shoulder arthroplasty using a patient-specific baseplate to address severe glenoid deficiency

Background The purpose of this study was to describe outcomes of patients undergoing reverse total shoulder arthroplasty (rTSA) using a patient-specific, custom glenoid component to address severe glenoid deficiency. Methods Retrospective chart review identified patients at a single institution undergoing rTSA using the glenoid vault reconstruction system (VRS) between 2017 and 2022. Radiographic evaluation, range of motion and patient-reported outcome (PRO) measures, complications, and re-operations were assessed. Results Fourteen shoulders were included. There was 100% implant survivorship of the glenoid baseplate at mean follow-up of 26.6 months. Mean range of motion improved in forward elevation (62–106 degrees), abduction (41–100 degrees), and external rotation (11–36 degrees). In 7 of 13 patients available for PRO collection, the mean final Visual Analog Pain Scale (VAS) score was 1.29, Single Assessment Numeric Evaluation (SANE) score was 72.14, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score was 77.14, and Penn Shoulder score was 72.26. Conclusions Use of this custom glenoid resulted in encouraging clinical and radiographic outcomes, with no failures in implant survivorship seen at early follow-up. Larger prospective studies with longer-term follow-up should be undertaken in order to better determine the efficacy and longevity of this implant. Study Design Retrospective case series; Level of evidence, 4.

Intra-articular soft arthroscopic Latarjet technique as a Bankart-plus procedure for type V superior labrum anterior-posterior lesion: lower rate of instability recurrence and better functional outcomes of a prospective cohort study.

Intra-articular soft arthroscopic Latarjet technique (in-SALT) involves augmentation of arthroscopic Bankart repair (ABR) with soft tissue tenodesis of long head of biceps to upper subscapularis. This study was conducted to investigate superiority of outcomes of in-SALT-augmented ABR over those of concurrent ABR and anterosuperior labral repair (ASL-R) in management of type V superior labrum anterior-posterior (SLAP) lesion. This prospective cohort study (conducted between January 2015 and January 2022) included 53 patients with arthroscopic diagnosis of type V SLAP lesion. Patients were allocated into 2 consecutive groups: group A of 19 patients managed with concurrent ABR/ASL-R and group B of 34 patients managed with in-SALT-augmented ABR. Outcome measurements included 2-year postoperative pain, range of motion, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe instability scores. Failure was defined as frank/subtle postoperative recurrence of glenohumeral instability or objective diagnosis of Popeye deformity. The statistically matched studied groups showed significant postoperative improvement in outcome measurements. However, group B demonstrated significantly better 3-month postoperative visual analog scale score (3.6 vs. 2.6, P=.006) and 24-month postoperative external rotation at 0° abduction (44° vs. 50°, P=.020) and ASES (84 vs. 92, P<.001) and Rowe (83 vs. 88, P=.032) scores. Rate of postoperative recurrence of glenohumeral instability was relatively lower in group B (10.5% vs. 2.9%, P=.290). No Popeye deformity was reported. For management of type V SLAP lesion, in-SALT-augmented ABR yielded a relatively lower rate of postoperative recurrence of glenohumeral instability and significantly better functional outcomes compared with concurrent ABR/ASL-R. However, currently reported favorable outcomes of in-SALT should be validated via further biomechanical and clinical studies.

Factors associated with humeral stem revision in anatomic to reverse total shoulder arthroplasty revision.

Recent advances in implant technology have allowed for modular or platform humeral stem insertion during initial anatomic total shoulder arthroplasty (TSA). These systems allow for humeral stem retention during conversion to reverse TSA (RTSA). However, some patients still require humeral stem revision when undergoing revision to RTSA. The purpose of this study was to evaluate the association between patient-specific factors and radiographic parameters with humeral stem revision vs. retention during conversion from TSA to RTSA. Retrospective chart review was conducted for patients who underwent a revision TSA to RTSA between January 2010 and May 2022 at a single institution. Patients were included if their prosthesis included a convertible humeral stem. Patient demographic information, surgical details, and postoperative outcomes and complications were collected. Radiographic parameters were measured by 2 graders on radiographs taken prior to the revision procedure. The need for humeral stem revision and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (preoperative and 2 years) were also noted. Statistical analysis was performed using chi-square test for categorical variables and t test for continuous variables. One hundred seven patients were included, with 52 undergoing humeral stem revision. Patients were revised an average of 51.0±54 months after primary TSA. Younger patient age (63.6 vs. 68.5 years, P=.017) and use of a lateralized glenosphere (1.6 mm vs. 0.4 mm, P<.001) were significantly associated with need for humeral stem revision. Glenoid to humeral head cut distance (28.3 mm vs. 26.3 mm, P=.076) approached significant association with the need for humeral stem revision. All other measurements were not associated with the need for humeral stem revision. Improvement of ASES scores at 2 years' follow-up was higher in the nonrevised group (increase of 33.4 points) than the revision group (23.3), but this did not reach significance (P=.149). Estimated blood loss and surgical time were significantly higher in the stem revision group than the non-revised group (P=.048 and P<.001, respectively). Younger patients and those receiving a lateralized glenosphere were more likely to undergo humeral stem revision during conversion from TSA to RTSA. Glenoid to the humeral head cut distance should be studied further as a potential indication for humeral stem revision, as it correlates with the space available for a revision implant. This information can guide surgeons with preoperative planning for a revision arthroplasty.

Outcome of intraoperative injection of collagen in arthroscopic repair of full-thickness rotator cuff tear: a retrospective cohort study.

Rotator cuff (RC) pathologies are considered the most common cause of shoulder disability and pain. Arthroscopic repair of RC tears has proven to be an effective operation. Nonhealing and retear remain significant clinical problems and a challenge to surgeons. In addition, the essential biological augment to enhance RC tendon-bone healing is still under research. The purpose of the study was to assess the safety and efficacy of injection of atelocollagen and acellular dermal matrix (ADM) allograft in arthroscopic repair of full-thickness RC tears. From January 2018 to March 2020, a total of 129 patients with full-thickness RC tear were treated by arthroscopic repair only (group 1, n=36, with a mean age=63.2 years), arthroscopic repair together with atelocollagen 1-mL injection (group 2, n=44, with a mean age=63 years), or RC tears together with ADM allograft 1-mL injection (group 3, n=49, with a mean age=64.6 years). They were prospectively studied. This study included patients with a repairable full-thickness tear of the supraspinatus tendon size <5 cm. We excluded patients with isolated tears of the subscapularis tendon, those with a previous shoulder surgery, and those who had any type of injection for less than 6 weeks. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Constant Shoulder score, visual analog scale pain score, and range of motion were evaluated preoperatively, at 3, 6, and 12 months of the postoperative period and the final follow-up. In addition, magnetic resonance imaging was performed at 2 months and 12 months postoperatively. The mean follow-up period was 20 months. All groups showed improvement in functional and pain score at the final follow-up; however, there is no superior outcome among the 3 groups (P>.05). After 2 months, the nonhealing rate was 11% (4 of 36) for group 1, 4% (2 of 44) for group 2, and 2% (1 of 49) for group 3 (P>.05). The retear rates after 12 months was 19.4% (7 of 36) for group 1, 13.6% (6 of 44) for group 2, and 20.4% (10 of 49) for group 3 (P>.05). Adverse events were not detected in any groups. Our study did not show superior clinical or radiologic outcomes of atelocollagen and ADM allograft injections in arthroscopic RC repair over 12 months of follow-up in comparison to the control group. However, adverse events related to atelocollagen and ADM allograft injection were not observed.

Functional and radiographic results of anatomic total shoulder arthroplasty in the setting of subscapularis dysfunction: 5-year outcomes analysis

Subscapularis management is a critical component to the success of anatomic total shoulder arthroplasty (TSA). Failure to heal the subscapularis can result in pain, weakness, loss of function, and revision. However, not all patients have poor outcomes. The purpose of this study is to compare patients with normal and dysfunctional subscapularis function following TSA in regard to (1) patient-reported outcome measures (PROMs); (2) range of motion (ROM) and strength; (3) achievement of minimal clinically important differences (MCIDs); and (4) specific functional internal rotation tasks. A retrospective review of patients treated with TSA for osteoarthritis with a minimum 2-year follow-up was performed to identify patients with subscapularis dysfunction. Subscapularis dysfunction was diagnosed when any degree of weakness in internal rotation was detected on physical examination (positive belly press sign). These patients were case controlled matched on a 1:3 ratio to patients with normal subscapularis function based on age and sex. PROMs, measured active motion, revision rates, patient satisfaction, and postoperative radiographic findings were compared. Population-specific institutional anchor-based MCID values were used to compare the improvement in PROM. Of the 668 patients included, 34 patients (5.1%) demonstrated evidence of subscapularis dysfunction. Mean follow-up for the normal subscapularis function cohort was 63.4±29.7 and 58.7±26.8 for the dysfunctional subscapularis cohort. Patients with subscapularis dysfunction demonstrated significantly worse postoperative Simple Shoulder Test, Single Assessment Numerical Evaluation, visual analog scale (VAS) function, VAS pain, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores with higher rates of unsatisfactory results when compared to patients with normal subscapularis function. Abduction, elevation, internal rotation ROM, along with supraspinatus and external rotation strength were also significantly worse in the dysfunctional group. Similarly, these patients were more likely to have decreased ability to perform functional internal rotation tasks, with only 47% of the patients being able to reach the small of their back compared to 85% with normal subscapularis function. Radiographically, the dysfunctional cohort demonstrated higher rates of anterior subluxation (56% vs. 7%; P<.001) and glenoid loosening (24% vs. 5%; P=.004). Similarly, revision rates were significantly higher for patients with subscapularis dysfunction (8 patients, 23.5%). Nonetheless, the dysfunctional subscapularis cohort demonstrated improvements in VAS pain (4.0±3.7) and ASES (46.4±35.9) scores that exceeded MCID thresholds. Patients who develop subscapularis dysfunction after TSA have significantly worse PROMs, ROM, functional tasks of internal rotation, and radiographic outcomes, as well as increased rates of revision. Although patients show worse outcomes and high revision rates compared with their normal-functioning counterparts, these patients maintained improvement above MCID thresholds for pain and function at a mean 5-year follow-up.

Poster 186: Cannabidiol for Post-Operative Pain Control after Arthroscopic Rotator Cuff Repair Demonstrates No Functional Deficits at 1-Year

Objectives: Cannabidiol (CDB) has been recently shown to positively impact patient pain and satisfaction immediately after arthroscopic rotator cuff repair. However, it is unclear if addition of CBD to a post- operative regimen will cause any changes in clinical outcomes. The purpose of this study is to evaluate 1-year functional outcomes among patients who previously underwent arthroscopic rotator cuff repair (ARCR) and received buccally-absorbed cannabidiol for post-operative pain management. We hypothesize that there will be no clinical differences in pain or shoulder function at one year follow up comparing those who receive CBD versus a placebo. Methods: Included patients had previously completed participation in a FDA-sanctioned, multi-center, placebo-controlled, randomized, double-blinded trial to evaluate the potential analgesic effects of CBD post-ARCR. The experimental group post-operatively received 25-mg of CBD (Oravexx, Orcosa Pharmaceuticals, USA) TID if &lt; 80-kg and 50-mg of CBD TID if &gt; 80-kg for 14 days, with control groups receiving an identical placebo. Patients were contacted one year following their date of surgery to obtain the following patient-reported outcome scores: the Visual Analogue Scale (VAS) for pain and satisfaction, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES), and the Single Assessment Numeric Evaluation (SANE) rating. These scores, as well as ASES sub-components, were compared between the CBD group and placebo group. Continuous variables were compared within groups with Wilcoxon signed rank test and between groups with Kruskal-Wallis test. Fisher’s exact test was used to compare categorical variables between groups. P-values &lt; 0.05 were considered significant. Results: Overall, 62 patients of the 72 patients currently eligible for 1-year follow-up were recruited, achieving a response rate of 86.1%. There were no significant differences in age, sex, or BMI between the two cohorts. There were no significant differences found between placebo and CBD cohorts in the overall ASES score (95.1% vs 91.2%, p = 0.288); furthermore, no differences (p &gt; 0.05) were found in each component of the 10-question daily activities of living scale. There were no significant differences with respect to the amount of anti-inflammatory pain medication taken on an average day, as reported on the ASES between placebo and CBD cohorts (0.23 pills ± 0.82 vs 0.50 ± 1.39; p = 0.365). No patients (0%) reported using any stronger pain medications, including opioids. There were no significant differences found in VAS pain score (0.77 ± 1.25 vs 0.91 ± 1.75, p = 0.721), VAS satisfaction (97.1% vs 97.2%, p = 0.927), and SANE score (92.4 vs 87.0, p = 0.065). All patients (100%) stated that surgery had met their expectations. Conclusions: Peri-operative use of CBD for pain control among patients undergoing ARCR does not result in any significant deficits in patient-reported pain, satisfaction, or functional outcomes at 1-year post-operatively compared to a placebo control. These findings suggest that CBD can be considered in a post-operative multimodal pain management regimen without long-term detrimental effects.

Western Ontario Osteoarthritis of the Shoulder Index (WOOS) - a validation for use in proximal humerus fractures treated with arthroplasty

BackgroundThe Swedish shoulder and Arthroplasty Registry (SSAR) use the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) as their shoulder-specific score in the follow-up. WOOS is not yet validated for use as the Patient Reported Outcome Measurement (PROM) for proximal humerus fractures (PHF) treated with shoulder hemiarthroplasty (SHA) in the Swedish registry. The aim of this study was to examine the validity, the reliability and the responsiveness of WOOS as a PROM for proximal humerus fractures treated with shoulder arthroplasty.MethodsData was collected from the SSAR from the 1st of January 2008 to the 31st of June 2011. A total of 72 subjects were identified with at least 1 year of follow-up. Of these 43 completed all the shoulder-specific PROM together with a clinical examination, including a WOOS retest and general health scores. A group of 29 did not undergo any clinical examination, but they completed all the questionnaires not requiring a clinical examination. The validity was assessed with WOOS compared to satisfaction level, and the Spearman rank coefficient was used for the correlation between WOOS and the shoulder-specific scores (Constant-Murley Score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and EQ-5D. For reliability, Intra Class Correlation (ICC) was used for the test–retest assessment and Cronbach´s alpha for the construct reliability.ResultsThe validity for WOOS had an excellent correlation (> 0.75) with all the shoulder-specific scores and a good correlation (> 0.6) with EQ-5D.The reliability with the test–retest of the total WOOS score and the subgroups had an excellent correlation. Cronbach´s alpha also supports the construct of WOOS. There were no floor or ceiling effects.ConclusionsWe found that WOOS is a reliable tool for evaluating patients with SHA after PHF. Based on our study, we recommend the continued use of WOOS in shoulder arthroplasty registries and observational studies.

Oral Corticosteroids versus Exercises on Treatment of Frozen Shoulder: A randomized, Single-blinded study.

Many treatment strategies have been described for the management of frozen shoulder. However, to date no randomized controlled trial has directly compared the efficacy of exercise and oral corticosteroids. The aim of this study was to determine whether pain, range of motion, and function differ between patients with frozen shoulder randomized to treatment with exercise or oral corticosteroids. This prospective, randomized, assessor-blinded trial was performed to compare the effectiveness of exercise and oral corticosteroids in patients with frozen shoulder. Overall, 33 patients with FS were randomly assigned to receive either exercise (n=17) or oral corticosteroids (n = 16). The exercise was applied 2 times per week for 6 weeks for 12 visits and patients in oral corticosteroids group received prednisolone for 4 weeks. Participants were assessed at baseline, after 6-weeks and at the 12-week follow-up. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) and visual analog scale (VAS). The secondary outcomes were American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES), range of motion, and hospital anxiety and depression (HAD). scale. Repeated-measures analysis of covariance (ANCOVAs) with baseline scores as the covariates were used to determine between-group differences. An intention-to-treat analysis was performed using the multiple imputation method to impute values for all missing data. Planned pairwise comparisons demonstrated significant improvements in pain relief and functional outcomes in both groups at the 6- and 12-week follow-ups compared to baseline. There were no significant time-by-group interactions between-group differences noted for the DASH (F=0.470, p= 0.93), VAS (F=0.006, p=0.94), flexion range of motion (ROM) (F=2.78, p=0.1), internal rotation ROM (F=3.440, p=0.07) and ASES (F=0.470, p=0.49). The overall group-by-time interaction for the 2×3 mixed-model ANCOVA using baseline scores as a covariate was significant for the abduction range (F=4.460, p=0.04) and external rotation range of motion (F=12.100, p = 0.002) in favor of the exercise group CONCLUSIONS: The study demonstrated that while both groups achieved significant improvements at the 6-, and 12-week follow-ups, the exercise group was superior in terms of abduction and external rotation range of motion. Additionally, even though both groups were improved, the effect sizes were larger in the exercise group. Considering the systemic side effects of oral corticosteroids, even at low doses, a well-planned exercise program that considers pain may be a good option for frozen shoulder.

Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.

Indications for reverse total shoulder arthroplasty (RSA) have expanded to include individuals with intact rotator cuffs such as patients with severe glenoid deformity or with concern of future rotator cuff insufficiency. The purpose of this study was to compare outcomes of RSA with an intact rotator cuff to RSA for cuff arthropathy and anatomic total shoulder arthroplasty (TSA). We hypothesized that outcomes of RSA with an intact rotator cuff would be comparable to RSA for cuff arthropathy and TSA but with diminished range of motion (ROM) compared with TSA. Patients at one institution who underwent RSA and TSA between 2015 and 2020 with minimum 12-month follow-up were identified. RSA with preservation of the rotator cuff (+rcRSA) was compared to RSA for cuff arthropathy (-rcRSA) and anatomic TSA (TSA). Demographics and glenoid version/inclination were obtained. Pre- and postoperative ROM; patient-reported outcomes including visual analog scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores; and complications were obtained. Twenty-four patients underwent+rcRSA, 69 underwent -rcRSA, and 93 underwent TSA. There were more women in the +rcRSA cohort (75.8%) than in the -rcRSA (37.7%, P=.001) and TSA (37.6%, P=.001) cohorts. Mean age of the +rcRSA cohort (71.1) was greater than that of TSA (66.0, P=.021) but similar to that of -rcRSA (72.4, P=.237). Glenoid retroversion was greater in +rcRSA (18.2°) compared with -rcRSA (10.5°, P=.011) but was similar to TSA (14.7°; P=.244). Postoperatively, there were no differences in VAS or ASES between+rcRSA vs. -rcRSA and +rcRSA vs. TSA. SSV was lower in +rcRSA (83.9) compared with -rcRSA (91.8, P=.021), but was similar to TSA (90.5, P=.073). Similar ROM was achieved in forward flexion, external rotation, and internal rotation at final follow-up between+rcRSA and -rcRSA, but TSA had greater external rotation (44° vs. 38°, P=.041) and internal rotation (6.5° vs. 5.0°, P=.001) compared with+rcRSA. There were no differences in complication rates. At short-term follow-up, preservation of the rotator cuff in RSA demonstrated similarly excellent outcomes and low complication rates compared with RSA with a deficient rotator cuff and TSA, except for slightly lower internal and external rotation compared with TSA. Although multiple factors deserve consideration when choosing between RSA and TSA, RSA with preservation of the posterosuperior cuff is a viable treatment option for glenohumeral osteoarthritis, particularly in patients with severe glenoid deformity or those at risk for future rotator cuff insufficiency.

Humeral Loosening in Reverse Shoulder Arthroplasty: An Analysis of 2,000 Cases.

Humeral loosening is a rare complication in reverse shoulder arthroplasty (RSA) representing approximately 1% of total complications. The purpose of this study is to identify patients who underwent RSA and were revised due to loosening of the humeral component, identify patients who are at increased risk, and report on their surgical outcomes. A retrospective review of all patients who received a primary RSA or revision RSA (rRSA) by a single surgeon from 2002-2021 identified a total of 1,591 primary RSA and 751 rRSA procedures. These procedures were then organized based on indication for surgery. Further analysis was performed to identify RSAs that were subsequently revised due to aseptic loosening of the humeral component. A total of 41 surgeries met inclusion criteria for the study, which was any RSA or rRSA that was revised due to loosening of the humeral component. Exclusion criteria was revision for a reason other than humeral loosening, neurogenic arthritis, or revision for loosening that was not originally implanted by the senior author (9 surgeries). Ultimately, 32 surgeries met criteria for further analysis. These 32 surgeries were organized by indication for preceding RSA or rRSA and were assessed for an association between indication for RSA/rRSA and eventual revision for humeral loosening. Additionally, these procedures were compared to a "control cohort" of procedures that were not revised and that had minimum 2-years follow-up. To assess outcomes for these patients, pre- and postoperative SST, ASES, and ranges of motion were compared. Twenty procedures had sufficient data for outcomes analysis and were followed for an average of 54 months (range: 24-132 months). In primary RSAs, procedures performed for fracture or fracture sequelae were associated with revision for humeral-sided loosening (p = 0.009). In rRSAs, procedures performed for failed hemiarthroplasty for CTA were associated with re-revision for humeral-sided loosening (p = 0.009). Nine percent of patients revised for humeral loosening required re-revision for recurrent humeral loosening. Analysis of patients with 2-year clinical follow-up for humeral-sided loosening showed improvement in ASES pain (p = 0.014), ASES function (p = 0.042), and total ASES scores (p = 0.007). Humeral loosening is rare in RSA. In our cohort, 0.7% of primary RSAs performed and 2.8% of rRSAs performed were eventually revised for humeral loosening. Revisions of RSA for humeral loosening yield modest clinical improvements. Re-revision for humeral loosening was 6.3% of patients in our cohort.

Two-Year Outcomes of the Reverse Humeral Reconstruction Prosthesis.

Extensive proximal humeral bone loss in the setting of shoulder arthroplasty represents a difficult challenge for the treating surgeon. Achieving adequate fixation with standard humeral prostheses can be problematic. Allograft-prosthetic composites are a viable solution for this problem, however high rates of complications have been reported. Modular proximal humeral replacement systems are another potential solution, but there is a paucity of outcome data on these implants. This study reports the two-year minimum follow-up outcomes and complications of a single system reverse proximal humeral reconstruction prosthesis (RHRP) for patients with extensive proximal humeral bone loss. We retrospectively reviewed all patients with minimum two-year follow-up who underwent implantation of a RHRP for either 1) failed shoulder arthroplasty or 2) proximal humerus fracture with severe bone loss (Pharos 2 and 3) and/or sequelae thereof. Forty-four patients met inclusion criteria (average age 68.3 ± 13.1 years). The average follow-up was 36.2 ± 12.4 months. Demographic information, operative data, and complications were recorded. Pre- and postoperative range of motion (ROM), pain, and outcome scores were assessed and compared to the MCID and SCB for primary rTSA where available. Of the 44 RHRPs evaluated, 93% (n=39) had undergone prior surgery and 70% (n=30) were performed for failed arthroplasty. ROM improved significantly in abduction by 22° (P = .006) and forward elevation by 28° (P = .003). Average pain on a daily basis and pain at worst improved significantly, by 2.0 points (P < .001) and 2.7 points (P < .001), respectively. Mean SST score improved by 3.2 (P < .001), Constant score by 10.9 (P = .030), ASES score by 29.7 (P < .001), UCLA score by 10.6 (P < .001), and SPADI score by 37.4 (P < .001). A majority of patients achieved the MCID for all outcome measures assessed (56-81%). The SCB was exceeded by half of patients for forward elevation and the Constant score (50%), and exceeded by the majority of patients for the ASES score (58%) and UCLA score (58%). The complication rate was 28%; the most common complication was dislocation requiring closed reduction. Notably, there were no occurrences of humeral loosening requiring revision surgery. This data demonstrates that the RHRP resulted in significant improvements in ROM, pain, and PROMs, without the risk of early humeral component loosening. RHRP represents another potential solution for shoulder arthroplasty surgeons when addressing extensive proximal humerus bone loss.

Improved Yet Varied Clinical Outcomes Observed With Comparison of Arthroscopic Superior Capsular Reconstruction Versus Arthroscopy-Assisted Lower Trapezius Transfer for Patients With Irreparable Rotator Cuff Tears

To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) and arthroscopy-assisted lower trapezius tendon transfer (LTT) for posterosuperior irreparable rotator cuff tears (IRCTs). Over an almost 6-year period (October 2015 to March 2021), all patients who underwent IRCT surgery with a minimum 12-month follow-up period were identified. For patients with a substantial active external rotation (ER) deficit or lag sign, LTT was preferentially selected. Patient-reported outcome scores included the visual analog scale (VAS) pain score, strength score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. We included 32 SCR patients and 72 LTT patients. Preoperatively, LTT patients had more advanced teres minor fatty infiltration (0.3 vs 1.1, P= .009), a higher global fatty infiltration index (1.5 vs 1.9, P= .035), and a higher presence of the ER lag sign (15.6% vs 48.6%, P < .001). At a mean follow-up of 2.9 ± 1.3 years (range, 1.0-6.3 years), no differences in patient-reported outcome scores were observed. Postoperatively, SCR patients had a lower VAS score (0.3 vs 1.1, P= .017), higher forward elevation (FE) (156° vs 143°, P= .004), and higher FE strength (4.8 vs 4.5, P= .005) and showed greater improvements in the VAS score (6.8 vs 5.1, P= .009), FE (56° vs 31°, P= .004), and FE strength (1.0 vs 0.4, P < .001). LTT patients showed greater improvement in ER (17° vs 29°, P= .026). There was no statistically significant between-cohort difference in complication rate (9.4% vs 12.5%, P= .645) or reoperation rate (3.1% vs 10%, P= .231). With adequate selection criteria, both SCR and LTT provided improved clinical outcomes for posterosuperior IRCTs. Additionally, SCR led to better pain relief and restoration of FE whereas LTT provided more reliable improvement in ER. Level III, treatment study with retrospective cohort comparison.

Clinical outcomes and return to play in softball players following SLAP repair or biceps tenodesis.

Shoulder pain due to labral tears and biceps tendonitis is commonly found in softball players. Surgical options include labral repair and biceps tenodesis. Although past studies are limited by heterogeneous study groups from multiple sports, this is the first study that assesses clinical outcomes and return to play rates for fast-pitch softball players. The purpose of this study was to evaluate the clinical outcomes and return to play for fast-pitch softball players treated for a superior labrum anterior posterior (SLAP) tear and recalcitrant biceps tendonitis with a biceps tenodesis compared with a traditional SLAP repair. We hypothesized that the biceps tenodesis would have comparable outcomes with a faster return to play compared with SLAP repair. We performed a retrospective analysis on fast-pitch softball players treated surgically for SLAP tear, recalcitrant biceps tendonitis, or a combination between 2001 and 2019 at our institution. Inclusion criteria were fast-pitch softball players who underwent biceps tenodesis or a SLAP repair with greater than 2-year follow-up. Exclusion criteria involved slow-pitch softball players, patients with less than 2-year follow-up, and patients who had undergone concomitant procedures on the ipsilateral shoulder at the time of SLAP repair or biceps tenodesis. Follow-up was either self-reported through OBERD, a patient-reported outcomes (PRO)-managing software, or achieved over the phone. Follow-up data included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Andrews Carson Score, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score, Numeric Rating Scale for Pain, and our institution-specific return-to-play questionnaire. We statistically compared players who underwent biceps tenodesis or a SLAP repair, and compared pitchers with position players using Student t tests and Fisher exact test with statistical significance determined to be P<.05. From 60 eligible patients identified, follow-up outcome data were successfully captured for 47 (78%). Of the 18 SLAP repair patients, 17 (94%) returned to full competition at an average of 7.9 months. Of the 29 patients who underwent biceps tenodesis, 27 (93%) returned to full competition at an average of 7.1 months. Statistical analysis of PRO scores for each group found no significant differences between any of the measures used to evaluate patient outcomes, including no statistical difference in pitchers compared with position players. In conclusion, this study demonstrated comparable outcomes between SLAP repairs and biceps tenodesis procedures among our study group of fast-pitch softball players. There was no significant difference between RTP times between the 2 groups.

Increased rates of subjective shoulder instability after Bankart repair with remplissage compared to Latarjet surgery.

Controversy exists as to the ideal management of young active patients with subcritical glenoid bone loss and an off-track Hill-Sachs lesion, and the Latarjet and arthroscopic Bankart with remplissage are effective surgical options. The purpose of this study was to compare rates of recurrent instability and reoperation, as well as patient-reported outcome measures, between Latarjet and arthroscopic Bankart repair with remplissage surgery patients. The authors hypothesized that there would be no difference in rates of recurrent instability, reoperation, and postoperative outcomes between patients who underwent Latarjet surgery and patients who underwent Bankart repair with concomitant remplissage postoperatively. All patients who underwent primary shoulder stabilization for shoulder instability from 2014 to 2019 were screened. Latarjet and Bankart repair with remplissage patients were included if arthroscopic surgery was performed in response to anterior shoulder instability. Recurrent instability, revision, shoulder range of motion, return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores) were compared between groups. Overall, 43 Latarjet patients (age: 29.8±12.1 years, 36 males 7 females) and 28 Bankart repair with remplissage patients (age: 28.2±8.8 years, 25 males 3 females) were included with a mean follow-up of 3.3±1.9 years. Patients who underwent Latarjet surgery had larger amounts of bone loss (19% vs. 11%, P<.001), a lower rate of off-track Hill-Sachs lesions (47% vs. 82%, P<.001), and more frequently had a history of chronic shoulder dislocations (88% vs. 43%, P<.001) compared to Bankart repair with remplissage patients. Latarjet patients less frequently reported feeling subjective shoulder instability after surgery (21% vs. 50%, P=.022), which was defined as feeling apprehension or experiencing a shoulder subluxation or dislocation event. There were no differences in rates of postoperative dislocation, revision, reoperation, or RTS, as well as patient-reported outcome scores, between groups (all P>.05). Despite differences in osseous defects, Latarjet and Bankart repair with remplissage patients had similar rates of clinical, patient-reported, and RTS outcomes at a mean of 3.3 years postoperatively. Latarjet surgery patients may be less likely to experience subjective shoulder instability postoperatively than patients who undergo Bankart repair with concomitant remplissage.

Association Between Preoperative Multidimensional Psychological Distress and Physical Function After Surgery for Sports-Related Injury.

Psychological distress after orthopaedic surgery can lead to worse outcomes, including higher levels of disability and pain and lower quality of life. The 10-item Optimal Screening for Prediction for Referral and Outcome-Yellow Flag (OSPRO-YF) survey screens for multiple psychological constructs relevant to recovery from orthopaedic injury and may be useful to preoperatively identify patients who may require further psychological assessment and possible intervention after surgery. To determine the association between the OSPRO-YF and physiological patient-reported outcomes (PROs). It was hypothesized that higher OSPRO-YF scores (indicating worse psychological distress) would be associated with worse PRO scores at time of return to sport. Case series; Level of evidence, 4. This study evaluated 107 patients at a single, academic health center who were assessed at a sports orthopaedics clinic and ultimately treated surgically for injuries to the knee, shoulder, foot, or ankle. Preoperatively, patients completed the OSPRO-YF survey as well as the following PRO measures: Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, numeric rating scale for pain; American Shoulder and Elbow Surgeons standardized shoulder assessment form for patients with shoulder injuries, the International Knee Documentation Committee score (for patients with knee injuries), and the Foot and Ankle Ability Measure (FAAM; for patients with foot or ankle injuries). At the time of anticipated full recovery and/or return to sport, patients again completed the same PRO surveys. Multivariable regression was used to evaluate the association between total OSPRO-YF score at baseline and PRO scores at the time of functional recovery. The baseline OSPRO-YF score predicted postoperative PROMIS Physical Function and FAAM Sports scores only. A 1-unit increase in the OSPRO-YF was associated with a 0.55-point reduction in PROMIS Physical Function (95% CI, -1.05 to -0.04; P = .033) indicating worse outcomes. Among patients who underwent ankle surgery, a 1-unit increase in OSPRO-YF was associated with a 6.45-point reduction in FAAM Sports (95% CI, -12.0 to -0.87; P = .023). The study findings demonstrated that the OSPRO-YF survey predicts certain long-term PRO scores at the time of expected return to sport, independent of baseline scores.

Traumatic rotator cuff tears with concomitant shoulder dislocation: tear characteristics and postsurgical outcomes.

Arthroscopic rotator cuff repair has been shown to have favorable outcomes following traumatic rotator cuff tear with concomitant shoulder dislocation. The aim of this study was to compare outcomes and tear characteristics between patients who underwent arthroscopic rotator cuff repair following traumatic tear with shoulder dislocation to those without dislocation. A retrospective review of 226 consecutive patients with traumatic rotator cuff tears who underwent arthroscopic repair between 2013 and 2017 with a minimum of 1-year follow-up was performed. Patients with traumatic dislocations and concomitant rotator cuff tears were placed in the Dislocation & Tear cohort (DT cohort) and were matched 1:2 with a second cohort sustaining traumatic cuff tears without dislocation (T cohort). Primary outcomes were injury characteristics including tendon involvement and atrophy and tear size and thickness. Secondary outcomes were postoperative strength and range of motion (ROM) in forward flexion (FF), external rotation (ER), and internal rotation (IR); patient-reported outcomes including Subjective Shoulder Value, visual analog scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; complications including repair failure (defined as symptomatic retear confirmed on postoperative magnetic resonance imaging), infection, adhesive capsulitis, and impingement; and rates of revision surgery. There were 18 patients in the DT Cohort and 36 patients in the T Cohort with no significant differences in time to final follow-up (50.4±24.5 months vs. 49.0±30.4 months, P=.73). The DT cohort displayed a larger mean tear size (34±12 mm vs. 19±12 mm, P=.01) and had greater infraspinatus involvement (78% vs. 36%, P=.004) and subscapularis involvement (72% vs. 39%, P=.02) than the T cohort. With regard to strength, postoperative ER strength was less likely to be 5/5 in the DT Cohort (53% vs. 94% of patients with 5/5 strength, P=.002) compared with the T cohort. With regard to ROM, the DT cohort had significantly lower preoperative FF (90°±55° vs. 149°±33°, P<.001), ER (36±21° vs. 52° ±14°, P=.02), and IR (5.4 ±2.1 vs. 7.5 ±1.2, P=.002) compared with the T cohort but had similar FF, ER, and IR outcomes postoperatively. There were no differences between the groups for complications and postoperative patient-reported outcomes. Traumatic rotator cuff tears with concomitant dislocations are associated with larger tear size and greater infraspinatus and subscapularis involvement than traumatic tears without dislocation. Arthroscopic repair of this injury is associated with lower preoperative ROM in FF, ER, and IR, as well as lower postoperative ER strength compared with traumatic tears without dislocation. Nonetheless, excellent patient-reported outcomes can be achieved following arthroscopic repair similar to patients without dislocation.

Pain associated psychological distress is more strongly associated with shoulder pain and function than tear severity in patients undergoing rotator cuff repair

Psychological distress has been associated with declining shoulder function in patients with rotator cuff tears (RCTs). Thus, we aimed to 1) evaluate the absence or presence of differences in shoulder pain, function, or pain-associated psychological distress in patients with increasing RCT severity and 2) assess whether psychological distress is associated with shoulder pain and function while adjusting for RCT severity. Consecutive patients who underwent rotator cuff repair and completed the optimal screening for prediction of referral and outcome (OSPRO) survey from 2019 to 2021 were included. OSPRO is composed of 3 domains that estimate pain associated psychological distress (negative mood, negative coping, and positive coping). Demographics, tear characteristics, and three patient reported outcomes (PRO), including the visual analog scale (VAS), Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) were collected. Patients were analyzed with analysis of variance and chi-square tests and stratified based on severity of RCTs into three groups: partial-thickness, small-to-medium full-thickness, and large-to-massive full-thickness tear. Linear regression analysis was used to evaluate the association between OSPRO scores and PROs, adjusting for severity of RCT. Eighty-four patients were included: 33 (39%) had partial-thickness, 17 (20%) had small-to-medium full-thickness, and 34 (41%) had large-to-massive tears. Regarding PROs and psychological distress, there were no significant differences amongst the three cohorts. In contrast, multiple significant associations between psychological distress and PROs were found. Within the negative coping domain, fear avoidance dimensions demonstrated the strongest correlation to PROs: fear-avoidance behavior for physical activity (ASES Beta-0.592, P<.001; VAS 0.357, P<.001) and work (ASES Beta-0.442, P<.001; VAS 0.274, P=.015). Several other dimensions within the negative coping, negative mood, and positive coping domains also demonstrated significant associations to PROs. These findings suggest that in patients undergoing arthroscopic rotator cuff repair, preoperative psychological distress can more strongly influence patient perception of shoulder pain and diminished shoulder function than RCT severity.

Impact of cervical spine pathology on outcomes after total shoulder arthroplasty.

Cervical spine pathology can affect the supporting muscles and function of the shoulder and contribute to shoulder and arm pain and hence may impact postoperative outcomes following shoulder arthroplasty. The purpose of this study was to evaluate the impact of a history of cervical spine arthrodesis and its timing, before or after total shoulder arthroplasty (TSA), on the outcomes of TSA. Our hypothesis is that a history of cervical arthrodesis (CA) will negatively impact patient outcomes after shoulder arthroplasty. A retrospective analysis was performed on a prospectively collected cohort at a single institution. Anatomic (aTSA) and reverse TSA (rTSA) patients with CA were identified and compared to a cohort of patients without CA (NCA) enrolled in an institutional registry from 2011 to 2020. Demographic characteristics, diagnoses, implant type, range of motion, adverse events, and clinical outcome metric scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Constant, Shoulder Function score, patient satisfaction) were recorded. Outcomes between cohorts were analyzed using conventional statistics as well as stratification by minimal clinically important difference and substantial clinical benefit (SCB) thresholds where applicable. Of the 573 TSAs evaluated, 48 (20a CA-aTSA and 28 CA-rTSA) had a history of CA and 525 (280 NCA-aTSA and 245 NCA-rTSA) had no history of CA. The CA-TSA (aTSA and rTSA) had lower Constant, ASES, and Shoulder Function scores postoperatively as well as less improvement in active external rotation and an overall lower satisfaction rating (P<.05 for all) compared with NCA-TSA. The adverse event rate in the CA-TSA cohort was higher compared with the NCA-TSA cohort (25% vs. 6.5% [rTSA; P=.004] and 24.5% vs. 11% [aTSA; P=.068]). Optimal cutoff analysis showed that a time from CA to TSA of greater than 1.33 years had a sensitivity of 75.0% and specificity of 75.0% in predicting achievement of SCB for ASES score. The current study demonstrates that patients with a history of CA undergoing shoulder arthroplasty results in lower postoperative functional outcomes, lower satisfaction, and higher rates of postoperative adverse events requiring surgical revision when compared to a cohort without a history of CA. Additionally, the current study demonstrates that a time interval of at least 16 months between CA and shoulder arthroplasty optimizes the chances of achieving SCB for ASES score.

Early postoperative recovery comparisons of superior capsule reconstruction to tendon transfers.

The management of massive posterosuperior rotator cuff tears is controversial, with no gold standard. Two recently developed techniques that have shown promising initial results include arthroscopic superior capsular reconstruction (SCR) and tendon transfers (latissimus or lower trapezius). However, there remains a scarcity of studies examining each procedure's early postoperative clinical outcomes individually or in comparison to each other. The purpose of this study is to compare the early postoperative recovery outcomes of tendon transfers (TTs) to SCR. Using the surgical outcomes system global database (Arthrex Inc.), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after SCR or TT. The time points analyzed included preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, VR-12 physical, and Single Assessment Numeric Evaluation (SANE). Overall, 163 patients underwent SCR and 24 arthroscopically assisted TT. The mean age for SCR and TT was 60 and 56 years, respectively. Postoperative recovery curves demonstrate that both procedures produced improved outcomes at each postoperative time point compared to preoperative. The pain and functional outcomes measures, including VAS, ASES, SANE, and VR-12 physical, were comparable for TT and SCRs, with similar recovery curves between the 2 techniques. Ultimately at 2 years postoperatively, there were no significant differences between the 2 techniques. Analysis of the early outcomes associated with arthroscopic treatment of massive posterosuperior rotator cuff tears demonstrated that the arthroscopically assisted tendon transfers and arthroscopic superior capsular reconstruction had similar pain and functional outcomes throughout the 2-year postoperative recovery period. Overall, the process of recovery appears equivalent between the 2 techniques. Future studies are needed to assess the outcomes of each technique and specific indications in an attempt to delineate an algorithm for the treatment of irreparable rotator cuff tears.

Complications following arthroscopic-assisted coracoclavicular stabilization in patients with unstable lateral clavicle fractures.

Lateral clavicle fractures are unstable and prone to nonunions, which is why they are often treated surgically rather than conservatively. Despite the variety of surgical techniques found in the literature, the best method for treating this rare fracture type has not yet been determined. Our case series aimed to describe a coracoclavicular (CC) reconstruction technique and to assess complications and patient outcomes 1year postoperatively. Nineteen patients who underwent surgery for an unstable lateral clavicle fracture (IIB, IIC, IID) with a suture button device (Dog Bone, Arthrex, Inc., Naples, FL, USA) were available for clinical and radiological follow-up. The assessments included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) score, the Constant Score (CS), the Subjective Shoulder Value (SSV), as well as the ipsilateral and contralateral coracoclavicular distance. The median age was 50years (IQR 28-59), 13 (68.4%) were male and the delay to surgery was 5days (IQR 2-9). The median clinical scores were 100 (ASES), 91 (CS), and 95 (SSV). The CC distance improved postoperatively (p = 0.003). However, nonunion occurred in 3 (15.8%) patients, 5 (26.3%) had other complications, and 5 (26.3%) needed revision surgery (4 plate removals and 1 pseudoarthrosis). The overall complication rate was 36.8%. Restoring the CC ligaments alone could not reliably achieve fracture stability, with more than one-third of cases in this series experiencing major complications. Given the high revision and nonunion rates, we do not recommend this type of surgical technique.