Improvement In American Shoulder And Elbow Surgeons Scores Research Articles

Poster 127: Repairs of Isolated Supraspinatus Tears: Single vs. Double Row Repairs Effect on Patient-Reported Outcomes Over a 2-Year Episode of Care

Objectives: Rotator cuff tears are the most common cause of shoulder disability, most commonly affecting the middle-aged population. Treatment for rotator cuff tears has changed dramatically over the past few decades, with overall volume of rotator cuff repairs (RCRs) increasing by approximately 1.6% each year. Simultaneously, there has been a shift from open, inpatient RCR to arthroscopic, outpatient procedures. Currently, well over 75% of patients undergo arthroscopic repair. The two most common techniques for rotator cuff fixation include single- or double-row fixation. Cadaveric and biomechanical studies demonstrate more complete reduction of the rotator cuff to its original footprint with double row repair, with a subsequent increase in anatomic restoration and biomechanical advantage. Many studies regarding clinical and functional outcomes, however, have not consistently demonstrated statistically significant differences between the two. The purpose of this study is to determine differences in patient-reported outcomes (PROs) after single- and double-row rotator cuff repairs at one and two years postoperatively. We hypothesize that single-row RCR will have noninferior clinical and patient-reported outcomes when compared to the double-row RCR cohort over the 2-year episode of care. Primary outcomes include baseline, 1-year and 2-year postoperative Single Assessment Numeric Evaluation (SANE) scores. Methods: All patients within a single health system that underwent primary rotator cuff repair between 2016 and 2022 were eligible for inclusion in this study. Exclusion criteria included incomplete baseline PROs, involvement of infraspinatus, subscapularis or teres minor tendons, revision surgeries, and concomitant fractures of the shoulder. Demographic information including age, sex, BMI, ASA score, injury characteristics and medical comorbidities were obtained through review of the patients’ electronic medical record. Surgical characteristics and technique were obtained from operative notes. PROs were collected prospectively and stored in a HIPAA-compliant electronic database until retrospective review for this study. Primary outcomes of interest include SANE score at baseline, 1-year and 2-years postoperatively. Secondary outcomes of interest included American Shoulder and Elbow Surgeons (ASES) scores, Patient-Reported Outcomes Measurement Information System (PROMIS) global 10 health questionnaire scores, rates of symptomatic retear and reoperation. Statistical analysis included descriptive analyses, paired t-tests, chi-squared test of independence and one-way ANOVA as appropriate. Statistical significance was defined as an alpha value of p ≤ 0.05. Results: A total of 237 patients met criteria for inclusion in this study, the majority of which were female (122, 51.5%). The average BMI was 30.0 ± 5.6, and the average age of the study participants was 59.0 ± 9.4 years. The majority of patients underwent double-row RCR (134, 56.5%). There were no significant differences in age, BMI, ASA score, gender, or smoking status between the two groups (Table 1). There was a higher observed frequency of diabetes mellitus than expected in the double-row cohort, however this did not reach statistical significance (p = 0.066). There was no significant difference in symptomatic retear, revision RCR, and other reoperation rates between the two cohorts (Table 2). The cohort that received double-row repair had a higher observed frequency of full-thickness tears than expected (p <0.001), however there was no significant difference in the observed frequencies of chronic and acute tears between the two cohorts. Baseline ASES scores did not differ significantly between the two cohorts (p = 0.505). Both cohorts saw statistically significant increase in ASES scores from baseline to 1-year (Figure 1). The difference between 1-year and 2-year ASES scores was less than a quarter of the improvement seen in the first year postoperatively, however, was still statistically significant in the double-row cohort and neared statistical significance in the single-row cohort (p = 0.048 and p = 0.075, respectively). While both cohorts saw significant improvement in ASES scores over the 2-year period, there was no significant difference in score change between the two cohorts. The baseline SANE scores were 40.7 ± 20.6 and 43.2 ± 21.4 for the double and single-row cohorts respectively. Each cohort saw statistically significant increases in SANE scores at 1 year postoperatively and continued to see significant increase between 1- and 2-years postoperatively (Figure 1). There was no statistically significant difference between the two cohorts regarding 1- and 2-year change in SANE scores. Conclusions: Over a 2-year period of care after RCR, patients saw significant improvement in SANE and ASES scores, with the majority occurring in the first year postoperatively. There were no statistically significant differences in patient-reported outcomes between patients that underwent double- and single-row repairs. Single- and double-row RCRs perform comparably over a 2-year episode of care, with excellent clinical and patient-reported outcomes. [Figure: see text]

Association of Preoperative Shoulder Osteoarthritis Severity Score With Change in American Shoulder and Elbow Surgeons Score at 2 Years After Rotator Cuff Repair.

The impact of early glenohumeral osteoarthritis (GHOA) on clinical outcomes after rotator cuff repair (RCR) remains unclear. The magnetic resonance imaging (MRI)-based Shoulder Osteoarthritis Severity (SOAS) score is a comprehensive approach to quantifying glenohumeral degeneration. To investigate the association between SOAS scores and changes in American Shoulder and Elbow Surgeons (ASES) scores in patients who underwent RCR. Cohort study; Level of evidence, 3. Two reviewers independently analyzed the preoperative MRI scans of 116 shoulders and assigned SOAS scores. Spearman correlation was used to calculate the association of mean SOAS scores with patient demographic characteristics and change in ASES scores over the 2-year follow-up period (ΔASES). Multivariate regression analysis was performed between the independent variables of patient age, sex, body mass index, and significant SOAS score components as determined by univariate analysis, with the dependent variable being ΔASES. Significance was defined as P < .05 for univariate analysis and P < .0125 after application of the Bonferroni correction for multivariate analysis. The mean ASES scores were 55.8 ± 18.6 preoperatively and 92.1 ± 12.1 at 2 years postoperatively. The mean preoperative SOAS score was 15.2 ± 7.1. On univariate analysis, the total SOAS score was positively correlated with patient age (r S = 0.41; P < .001), whereas ΔASES was negatively correlated with patient age (r S = -0.27; P = .0032). Increasing SOAS subscores for supraspinatus/infraspinatus tear size (r S = -0.28; P = .024), tendon retraction (r S = -0.23; P = .015), muscle atrophy (r S = -0.20; P = .034), paralabral ganglia (r S = -0.23; P = .015), and cartilage degeneration (r S = -0.21; P = .024) were negatively correlated with ΔASES. A negative correlation was found between increasing total SOAS score and ΔASES (r S = -0.22; P = .016). On multivariate analysis, increasing supraspinatus/infraspinatus tear size was significantly and negatively correlated with ΔASES (β = -3.3; P = .010). Increasing the total SOAS score was predictive of less improvement in ASES scores at 2 years postoperatively. On univariate analysis, SOAS subscores with the strongest negative correlations with ΔASES scores included tear size, muscle atrophy, tendon retraction, paralabral ganglia, and cartilage wear. On multivariate analysis, only tear size was significantly associated with a lower change in the ASES score.

Association Between Preoperative Patient Resilience and Patient-Reported Outcomes After Rotator Cuff Repair.

Mental and emotional health can affect outcomes after orthopaedic surgery, and patient resilience has been found to be significantly related to postoperative functional outcomes. To evaluate the relationship between preoperative patient resilience and 2-year postoperative patient-reported outcomes after rotator cuff repair (RCR). It was hypothesized that patients with low preoperative resilience will have worse patient-reported outcomes at 2 years after RCR versus those with high resilience. Cohort study; Level of evidence, 3. Patients who underwent primary arthroscopic RCR in 2020 at a single institution and completed the Brief Resilience Scale (BRS) preoperatively were identified. Other inclusion criteria were American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores at the 2-year follow-up. Outcomes were compared in patients as divided into low resilience (BRS score >1 SD below the mean), normal resilience (BRS score ≤1 SD of the mean), and high resilience (BRS score >1 SD above the mean) groups. Overall, 100 patients (52 male, 48 female; mean age, 60 ± 9 years) were included in this study. Mean BRS scores did not change significantly from preoperative to 2-year follow-up (3.8 ± 0.7 vs 3.9 ± 0.8, P = .404). All patients had preoperative ASES scores. Low-resilience patients (n = 17) had significantly lower preoperative ASES scores compared with normal (n = 64) and high resilience (n = 19) patients (35 vs 42 vs 54, respectively; P = .022). There were no significant group differences in postoperative outcomes (revision rate, ASES score, ASES score improvement from preoperative to 2-year follow-up, or SANE score). Multivariate analysis indicated that preoperative resilience was not significantly associated with ASES score improvement (β estimate = -5.64, P = .150), while resilience at 2-year follow-up was significantly related to ASES score improvement (β estimate = 6.41, P = .031). Patient-reported outcomes at 2-year follow-up did not differ based on preoperative patient resilience for arthroscopic RCR patients. Multivariate analysis also showed that preoperative resilience was not associated with improvement in ASES scores; however, resilience at 2-year follow-up was associated with ASES score improvement.

Better short-term outcomes of mini-open rotator cuff repair compared to full arthroscopic repair.

Rotator cuff tears commonly cause shoulder pain and functional impairment, prompting surgical intervention such as miniopen and arthroscopic methods, each with distinct benefits. This study aimed to compare the clinical outcomes and complications of these two approaches. A retrospective analysis was conducted on 165 patients who underwent rotator cuff repair using either arthroscopic-assisted mini-open or full arthroscopic approaches. Patient demographics, tear characteristics, clinical outcomes, and complications were assessed, with statistical analyses conducted to discern differences between the groups. Among the patients, 74 (53.2%) received the mini-open approach, while 65 (46.8%) underwent arthroscopic repair, with a mean follow-up of 19.91 months. The mini-open group exhibited significantly higher postoperative American Shoulder and Elbow Surgeons (ASES) scores compared to the arthroscopic group (P=0.002). Additionally, the mini-open group demonstrated a more significant improvement in ASES scores from preoperative to postoperative assessments (P=0.001). However, the arthroscopic method had a significantly longer operative time (P<0.001). Complications, including anchor placement issues, frozen shoulder, infection, and re-rupture, occurred in 17.3% of patients overall. Re-rupture rates were 13.5% for mini-open and 6.2% for full arthroscopic repair, with no significant difference between the two methods (P=0.317). Both the mini-open and arthroscopic methods yielded favorable clinical outcomes for rotator cuff tear treatment, but the mini-open group exhibited superior results. Surgeons should consider patient characteristics, tear attributes, and surgical expertise when selecting the appropriate technique. Level of evidence: III.

Midterm outcome of superior capsular reconstruction using doubled acellular human dermal allograft for irreparable rotator cuff tear

Thicker (folded) facia lata autografts have been shown to be superior to thinner grafts and single-layered acellular human dermal (HD) allografts for superior capsular reconstruction (SCR) in biomechanical studies. The aim of this study was to evaluate the mid-term clinical outcomes following SCR for irreparable supraspinatus tears using doubled (folded) HD allograft. Thirty-two patients who had undergone SCR using doubled HD allograft between February 2012 through January 2020 were recruited in a continuous manner in this retrospective study. The inclusion criteria were SCR performed for irreparable supraspinatus tear and a minimum of two years follow-up. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) score. The secondary outcome measures were complications and revision surgery. A subgroup analysis was performed between patients who received a "Standard" graft of mean 3mm thickness or a "Thick" graft of mean 4.4mm thickness. One patient was lost to follow-up. A total of 31 patients (31 shoulder joints) were analyzed with mean follow-up duration of 48 months (range, 25-96 months). Following surgery, there was significant improvement in ASES score from 18.1 ± 14.3 (preoperative) to 76.3 ± 25.1 (postoperative) (P < 0.001) with a satisfactory clinical outcome obtained in 83.8% of the patients. In a subset of eight patients completing five-years follow-up, clinical improvements were sustained. The percentage of patients with a clinically successful outcome was higher with thick grafts compared to patients with standard grafts, although this failed to reach statistical significance (94.4% vs 69.2%, RR=1.36, 95%CI 0.93-1.99, P = 0.13). One patient within the standard group underwent revision surgery. SCR for irreparable rotator cuff tears with doubled HD allograft results in improved clinical outcomes and low reoperation at mid-term follow-up duration.

Onlay patch augmentation in rotator cuff repair for moderate to large tears in elderly patients: clinical and radiologic outcomes.

This study evaluated the clinical and radiologic outcomes of onlay patch augmentation in rotator cuff repair for moderate-to-large tears in elderly patients. We reviewed 24 patients who underwent onlay augmentation with dermal allograft after arthroscopic rotator cuff repair from January 2017 to March 2020. Inclusion criteria were patients aged &gt;65 years with tears &gt;2.5 cm, who were followed for &gt;12 months after surgery, and patients who could raise their arms above 90° preoperatively. American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, pain visual analog scale (VAS), and VAS for satisfaction were used as clinical outcomes. For the evaluation of cuff integrity, magnetic resonance imaging scans were performed every 3 months after surgery. The results were compared before and after surgery in all patients and between the retear and intact groups. The average follow-up period was 16.38 months, and the mean age of patients was 71.05 years. All patients showed significant improvement in ASES score, Constant-Murley score, and pain VAS at the last evaluation. The average value of satisfaction VAS was 7.27/10. The retear rate was 25% (6/24) if Sugaya type 3 was categorized in the retear group, otherwise 16.7% (4/24), if Sugaya type 3 was categorized into the intact group. Irrespective of Sugaya type 3 being included in the retear group, there was no significant difference in outcome variables between the intact and retear groups during follow-up. In moderate-to-large rotator cuff tear in elderly patients, onlay patch augmentation improved clinical outcomes. Retear did not adversely affect clinical outcomes.

Similar Value Demonstrated in the Short-Term Outcomes of Superior Capsular Reconstruction and Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears

The purposes of this study were to investigate the difference in value (benefit to cost ratio) of dermal allograft superior capsular reconstruction (SCR) versus reverse total shoulder arthroplasty (rTSA) for the treatment of massive rotator cuff tears (MRCTs) without arthritis; to compare the patient populations selected for the operations and report pre- and postoperative functional data; and to understand other characteristics of the 2 operations, including operating time, use of institutional resources, and complications. A retrospective, single-institution analysis during the study period 2014-2019 with MRCT treated with SCR or rTSA by 2 surgeons with complete institutional cost data and minimum 1-year clinical follow-up with American Shoulder and Elbow Surgeons (ASES) score. Value was defined as ΔASES/(total direct costs/$10,000). Thirty patients underwent rTSA and 126 patients SCR during the study period with significant differences noted in patient demographics and tear characteristics between the groups (patients who underwent rTSA were older, less male, had more pseudoparalysis, had greater Hamada and Goutallier scores, and had more proximal humeral migration). Value was 25 and 29 (ΔASES/$10,000) for rTSA and SCR, respectively (P= .7). The total costs of rTSA and SCR were $16,337 and $12,763, respectively (P= .7). Both groups experienced substantial improvements in ASES scores: 42 for rTSA vs 37 for SCR (P= .6). The operative time for SCR was much longer (204 vs 108 minutes, P < .001) but complication rate lower (3% vs 13%, P= .02) versus rTSA. In a single institutional analysis of the treatment of MRCT without arthritis, rTSA and SCR demonstrated similar value; however, the value calculation is highly dependent on institution specific variables and duration of follow-up. The operating surgeons demonstrated different indications in selecting patients for each operation. rTSA had an advantage over SCR in shorter operative time, whereas SCR demonstrated a lower complication rate. Both SCR and rTSA are demonstrated to be effective treatments for MRCT at short-term follow-up. III, retrospective comparative study.

Outcomes of shoulder arthroplasty by year of index procedure: are we getting better?

The purpose of this study was to determine whether postoperative patient-reported outcomes improved over time following anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We performed a retrospective analysis of prospectively collected patient-reported outcomes from our institution's registry between 2008 and 2018 (N = 1899). American Shoulder and Elbow Surgeons (ASES) scores at a minimum of 2 years postoperatively were required. Univariable linear models were used to test the association between year of surgery and improvement in ASES scores at 2- and 5-year follow-up, as well as any association with age, sex, primary or revision surgery, hand dominance, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, and Walch classification. Multivariable models were created to analyze ASES score improvement by index year while controlling for significant factors. In the univariable analysis, 5-year ASES difference scores increased each year by a mean of 1.65 (P < .001; 95% confidence interval [CI], 0.75-2.55) for TSA, 2.50 (P = .014; 95% CI, 0.52-4.49) for RTSA, and 1.64 (P < .001; 95% CI, 0.81-2.47) for the overall population. Patient sex, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, Walch classification, and revision procedures were also significant factors affecting ASES scores. On multivariable analysis controlling for these factors, 5-year ASES difference scores were still significantly associated with year of surgery, increasing each year by a mean of 2.20 (P<.001; 95% CI, 0.91-3.50) for TSA, 4.83 (P < .001; 95% CI, 1.17-8.49) for RTSA, and 1.66 (P < .001; 95% CI, 0.81-2.51) for the entire population. Both anatomic TSA and RTSA patients reported increasing ASES difference scores at 5-year follow-up as time passed. These findings may indicate that advances in shoulder arthroplasty have resulted in better patient outcomes over time. Further research is needed to clarify which factors influence improvements in outcomes, particularly for revision procedures.

The Comparative Effect of Age on Clinical Outcomes Following Anatomic Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty.

At many institutions, the pendulum has swung toward reverse total shoulder arthroplasty (RTSA). Good results have been reported for patients older than 65 years with glenohumeral osteoarthritis with an intact rotator cuff, leading to questioning of the role of anatomic total shoulder arthroplasty (TSA) in the elderly. The purpose of this study was to compare outcome measures between TSA and RTSA patients using minimal clinically important difference (MCID) and substantial clinical benefit (SCB) as a function of age. Primary TSA or RTSA patients with American Shoulder and Elbow Surgeons (ASES) scores at 2-year follow-up were retrospectively identified from a prospective database. Patients with a diagnosis of inflammatory arthritis, infection, proximal humerus fracture, or revision TSA were excluded. Patients were stratified by age as younger than 65 years, 65 to 74 years, and 75 years or older. A total of 659 TSA and 172 RTSA patients were included. Total shoulder arthroplasty had a larger improvement in ASES scores compared with RTSA in patients aged 65 to 74 years and 75 years and older (P=.04 and P<.01, respectively). In patients aged 75 years or older, the percentages of patients achieving MCID were similar (93.1% TSA and 92.3% RTSA; P=.53); however, a higher percentage of TSA patients achieved SCB vs RTSA patients (90.5% vs 76.9%; P=.01). This study highlights the importance of indications and a shared decision-making model to ensure patient satisfaction. The results support a trend that primary RTSA is a viable option for low-demand patients aged 75 years or older; however, appropriately indicated TSA offers a potential for greater improvement in ASES scores and is more successful at achieving SCB compared with RTSA at 2-year follow-up. [Orthopedics. 2021;44(4):e600-e606.].

The effect of humeral stem alignment in reverse shoulder arthroplasty

BackgroundThe impact of stem alignment on hip arthroplasty outcomes has been thoroughly evaluated, but there is limited data assessing this relationship in reverse shoulder arthroplasty (RSA). In this study, we investigated the association of humeral stem alignment with patient outcomes following RSA. MethodsUsing our prospectively maintained institutional registry, we identified patients who underwent reverse shoulder arthroplasty between July 2015 and September 2017 with minimum 2-year follow-up. Two raters independently assessed stem alignment using full-length humeral view radiographs. Stem alignment was correlated to American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Scale (VAS) pain score, range of motion, complications, and scapular notching at 2-year follow-up. ResultsOf the 117 patients that fit our inclusion criteria, 68 (58%) had neutral or valgus alignment and 49 (42%) had varus alignment. ASES score, VAS pain score, range of motion, complications, and scapular notching showed no differences between the 2 cohorts at 2-years postoperatively. Change (mean, SD) in ASES scores (52.5 ± 17.7 vs. 41.3 ± 21.2, P = .01) and VAS pain scores (−5.7 ± 2.5 vs. −4.6 ± 2.6, P = .02) were greater in the neutral/valgus cohort compared to the varus cohort. Demographics analysis revealed that the neutral or valgus cohort had a larger female population (74% vs. 59%, P < .01) while men were more likely to be in the varus cohort. ConclusionHumeral stem alignment does not appear to affect clinical outcomes at 2-years postoperatively. Improvement in ASES score and VAS pain score were slightly inferior in varus patients, however this difference was not clinically relevant. There may be a correlation between male gender and varus alignment, likely due to better bone quality and larger musculature. Further investigation into the association between stem angulation and clinical outcomes is warranted. Levels of EvidenceLevel III; Retrospective Cohort Study.

Does Margin Convergence Reverse Pseudoparalysis in Patients with Irreparable Rotator Cuff Tears?

Margin convergence has been shown to restore muscle tension in a cadaveric model of a rotator cuff tear. However, the clinical utility of this technique remains uncertain for patients with pseudoparalysis caused by an irreparable rotator cuff tear. (1) For patients with massive irreparable rotator cuff tears, in what proportion of patients does margin convergence reverse pseudoparalysis? (2) In patients with massive irreparable rotator cuff tears, does margin convergence improve American Shoulder and Elbow Surgeons (ASES) scores? (3) What is the survivorship free from MRI evidence of retear after margin convergence? Between 2000 and 2015, we treated 203 patients for pseudoparalysis with a rotator cuff tear. Pseudoparalysis was defined as active elevation less than 90° with no stiffness, which a physical therapist evaluated in the sitting position using a goniometer after subacromial injection of 10 cc lidocaine to eliminate pain. Of those, we considered patients who underwent at least 3 weeks of unsuccessful nonoperative treatment in our hospital as potentially eligible. Twenty-one percent (43 of 203) who either improved or were lost to follow-up within 3 weeks of nonoperative treatment were excluded. A further 12% (25 of 203) were excluded because of cervical palsy, axillary nerve palsy after dislocation or subluxation, and development of severe shoulder stiffness (passive shoulder elevation < 90°). Repair was the first-line treatment, but if tears were considered irreparable with the torn tendon unable to reach the original footprint after mobilizing the cuff during surgery, margin convergence was used. When margin convergence failed, the procedure was converted to hemiarthroplasty using a small humeral head to help complete the repair. Therefore, 21% (42 of 203) of patients treated with regular repair (18% [36 of 203]) or hemiarthroplasty (3% [6 of 203]) were excluded. That left 93 patients eligible for consideration. Of those, 13 patients were lost before the minimum study follow-up of 2 years or had incomplete datasets, and 86% (80 of 93) were analyzed (49 men and 31 women; mean age 68 ± 9 years; mean follow-up 26 ± 4 months). Seventy-six percent (61 of 80) were not evaluated in the last 5 years. We considered reversal of pseudoparalysis as our primary study outcome of interest; we defined this as greater than 90° active forward elevation; physical therapists in care measured this in the sitting position by using goniometers. Clinical outcomes were evaluated based on the ASES score from chart review, active ROM in the shoulder measured by the physical therapists, and the 8-month Kaplan-Meier survivorship free from MRI evidence of retear graded by the first author. Pseudoparalysis was reversed in 93% (74 of 80) patients, and improvement in ASES scores was observed at the final follow-up (preoperative 22 ± 10 to postoperative 62 ± 21, mean difference 40 [95% CI 35 to 45]; p < 0.01). The 8-month Kaplan-Meier survivorship free from MRI evidence of retear after surgery was 72% (95% CI 63% to 81%). There were no differences in clinical scores between patients with and without retears (intact ASES 64 ± 24, re-tear ASES 59 ± 10, mean difference 6 [95% CI -5 to 16]; p = 0.27). Margin convergence can be a good option for treating patients with pseudoparalysis and irreparable rotator cuff tears despite the relatively high retear rates. The proportion of pseudoparalysis reversal was lower in patients with three-tendon involvement. Further studies will be needed to define the appropriate procedure in this group. Level IV, therapeutic study.

What Are the Predictors of Poor Patient-Reported Outcomes After Shoulder Instability Surgery?

Background:Prospectively collected responses to Patient Acceptable Symptom State (PASS) questions after shoulder instability surgery are limited. Responses to these outcome measures are imperative to understanding their clinical utility.Purpose/Hypothesis:The purpose of this study was to evaluate which factors predict unfavorable patient-reported outcomes after shoulder instability surgery, including “no” to the PASS question. We hypothesized that poor outcomes would be associated with male adolescents, bone loss, combined labral tears, and articular cartilage injuries.Study Design:Cohort study; Level of evidence, 2.Methods:Patients aged ≥13 years undergoing shoulder instability surgery were included in point-of-care data collection at a single institution across 12 surgeons between 2015 and 2017. Patients with anterior-inferior labral tears were included, and those with previous ipsilateral shoulder surgery were excluded. Demographics, American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, and surgical findings were obtained at baseline. ASES and SANE scores, PASS responses, and early revision surgery rates were obtained at a minimum of 1 year after the surgical intervention. Regression analyses were performed.Results:A total of 234 patients met inclusion criteria, of which 176 completed follow-up responses (75.2%). Nonresponders had a younger age, greater frequency of glenoid bone loss, fewer combined tears, and more articular cartilage injuries (P < .05). Responders’ mean age was 25.1 years, and 22.2% were female. Early revision surgery occurred in 3.4% of these patients, and 76.1% responded yes to the PASS question. A yes response correlated with a mean 25-point improvement in the ASES score and a 40-point improvement in the SANE score. On multivariate analysis, combined labral tears (anterior-inferior plus superior or posterior tears) were associated with greater odds of responding no to the PASS question, while both combined tears and injured capsules were associated with lower ASES and SANE scores (P < .05). Sex, bone loss, and grade 3 to 4 articular cartilage injuries were not associated with variations on any patient-reported outcome measure.Conclusion:Patients largely approved of their symptom state at ≥1 year after shoulder instability surgery. A response of yes to the PASS question was given by 76.1% of patients and was correlated with clinically and statistically significant improvements in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across patient-reported outcome measures, whereas sex, bone loss, and cartilage injuries were not.

Arthroscopic Superior Capsular Reconstruction With Mesh Augmentation for the Treatment of Irreparable Rotator Cuff Tears: A Comparative Study of Surgical Outcomes

Background: Arthroscopic superior capsular reconstruction (ASCR) is an alternative to open surgery for irreparable chronic rotator cuff tears (RCTs). This approach can provide static restraint while avoiding upward migration of the humeral head. However, graft tears and their effect on clinical outcomes after ASCR remain a debated topic. Purpose: To evaluate the clinical outcomes of ASCR with mesh augmentation for the treatment of irreparable RCTs. Study Design: Cohort study; Level of evidence, 3. Methods: The data of 72 patients with irreparable RCTs who underwent ASCR between 2013 and 2018 were retrospectively evaluated. Among them, 64 patients who met the inclusion and exclusion criteria were enrolled in this study. Fascia lata grafts augmented with a polypropylene mesh were used for 30 patients (mesh group), and grafts without mesh augmentation were used for 34 patients (control group). Clinical outcomes were evaluated using range of motion, the American Shoulder and Elbow Surgeons (ASES) questionnaire, and visual analog scale for pain. Radiological outcomes were evaluated according to acromiohumeral distance and stage of rotator cuff arthropathy. The status of fatty infiltration and graft integrity was evaluated using magnetic resonance imaging. Outcomes were assessed preoperatively and at the final follow-up. Results: Both groups showed improvement in clinical and radiological outcomes at the final follow-up. The mesh group demonstrated a larger improvement in ASES score (mean ± SD, 29.1 ± 15.8) than the control group (18.1 ± 15.9) (P = .006). The mean improvement in active forward flexion was significantly higher in mesh group (40°± 26°) than in control group (28°± 23°) (P = .003). The mean improvement in active external rotation was also significantly higher in the mesh group (11°± 5°) than in the control group (6°± 3°) (P = .004). Graft healing rate was significantly higher in the mesh group (83.3%) than in the control group (58.8%) (P = .039), and acromiohumeral distance was significantly greater in the mesh group (9.1 ± 2.4 mm) than in the control group (6.3 ± 1.8 mm) at the final follow-up (P = .001). Subgroup analysis revealed that patients with graft failure generally showed progression of fatty infiltration without improvement in the stage of rotator cuff arthropathy. Patients with intact grafts demonstrated a more substantial improvement in functional outcomes (ASES score and forward flexion motion). Conclusion: ASCR with mesh augmentation reduced graft failure rate to restore superior shoulder joint stability.

The effect of glenoid bone loss and rotator cuff status in failed anatomic shoulder arthroplasty after revision to reverse shoulder arthroplasty

We evaluated outcomes and the risk of re-revision in patients with a failed anatomic total shoulder arthroplasty (TSA) revised to a reverse shoulder arthroplasty (RSA) based on rotator cuff deficiency and glenoid bone loss. From 2004 to 2017, 123 patients with failed TSAs underwent revision to RSAs with minimum 2-year follow-up. Preoperative radiographs were evaluated to determine whether the glenoid component was fixed or loose. The rotator cuff was assessed intraoperatively and as intact or deficient. Patient outcomes including shoulder motion and American Shoulder and Elbow Surgeons (ASES) scores were obtained preoperatively and postoperatively. Patient outcomes were compared based on glenoid fixation and rotator cuff status. There were 18 TSAs revised to RSAs that underwent subsequent revision. The mean preoperative ASES score was 31 (95% confidence interval [CI], 29-33) with no difference in preoperative ASES scores based on glenoid status (P = .412) or rotator cuff status (P = .89). No difference in postoperative ASES score was found based on glenoid component status or rotator cuff status. However, improvement in the ASES score was greater with an intact rotator cuff (mean postoperative score, 67 [95% CI, 57-76] vs. 55 [95% CI, 50-60]; P = .025). The overall re-revision rate was 11.4%, with a mean time to re-revision of 22 months (range, 0-89 months). The odds ratio was 1.786 for subsequent revision in patients with glenoid loosening compared with those without loose glenoids on preoperative radiographs. There was an overall improvement in patient outcomes for failed TSAs revised to RSAs; however, patients with an intact cuff had a greater improvement in ASES scores.

Arthroscopic Capsulolabral Reconstruction for Posterior Shoulder Instability Is Successful in Adolescent Athletes.

Posterior shoulder instability is an increasingly common pathology recognized in athletes. Adolescent athletes are especially at risk for this condition due to the widespread participation in numerous sports, including both overhead throwing and collision activities. Little data are available regarding surgical outcomes in these athletes with only a single small case series (N=25) currently published. In total, 68 athletes (82 shoulders) with unidirectional posterior shoulder instability were treated with arthroscopic posterior capsulolabral reconstruction and underwent an evaluation at a mean of 36 months postoperatively. The average age for our cohort was 17.2 years (range, 14 to 19 y), with 66 males (80%) and 16 females (20%). A total of 55 athletes (67%) participated in contact sports and 32 athletes (39%) participated in overhead throwing. Thirty athletes (37%) participated in multiple sports. Preoperative and postoperative outcomes data were retrospectively reviewed, and included the American Shoulder and Elbow Surgeons (ASES) shoulder score, subjective stability score, strength, range of motion, and return-to-play status. Intraoperative findings and methods of fixation were also recorded. Mean ASES score improved from 48.6 to 85.7 (P<0.001) after surgery. There were also significant improvements in stability, pain, and functional scores after surgery. Contact, throwing, and multisport athletes all showed similar scores at preoperative and follow-up timepoints, and no differences were noted between these athlete groups for any patient-reported outcome measure. Female athletes tended to have significantly lower preoperative and postoperative ASES scores, specifically within the pain domain when compared with males. With regard to the method of internal fixation, patients who underwent capsulolabral plications with suture anchors showed a trend toward greater improvement in ASES scores which did not reach statistical significance. Overall, 89% of athletes were able to return to competition, with 71% returning to their preinjury level of play. In total, 8.5% of athletes failed their initial surgical procedure with continued pain or instability that required revision surgery. Arthroscopic capsulolabral reconstruction is a reliable treatment for unidirectional posterior shoulder instability in an adolescent population, and does well for athletes involved in a variety of sporting activities. Level IV-case series.

Clinical and Imaging Outcomes After Arthroscopic Superior Capsule Reconstruction With Human Dermal Allograft for Irreparable Posterosuperior Rotator Cuff Tears: A Minimum 2-Year Follow-Up

To report the clinical and structural outcomes for non-pseudoparalytic irreparable posterosuperior rotator cuff tears treated with superior capsule reconstruction (SCR) using dermal allograft (DA). Patients who underwent SCR using DA with a mean thickness of 3 mm for irreparable posterosuperior rotator cuff tears and underwent surgery at least 2 years earlier were included. Outcomes were assessed prospectively by the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; patient satisfaction; and visual analog scale for pain. Structurally, acromiohumeral distances (AHDs) were assessed both preoperatively and postoperatively (standard radiographs). Graft integrity was assessed by magnetic resonance imaging. Clinical failures were reported. We included 22 patients with a mean age of 56 years (range, 41-65 years) and a mean follow-up period of 2.1 years (range, 2-3 years). The ASES score improved from 54.0 to 83.9 (P < .001); the Single Assessment Numeric Evaluation score improved from 44.9 to 71.4 (P < .001); and Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) improved from 37.6 to 16.2 (P= .001). Of the patients, 85% achieved an improvement in the ASES score that exceeded the minimal clinically important difference (11.1 points). The median patient satisfaction rating was 8.5 (range, 1-10). The median preoperative visual analog scale score decreased from 4 to 0 (range, 0-3) postoperatively (P < .001). Complete radiographs of 19 of 22 patients (86%) were obtained at a mean of 5.2 months (range, 1.4-10 months) postoperatively and showed a significant increase in the mean AHD from 7.0 mm preoperatively to 8.3 mm postoperatively (P= .029). Postoperative magnetic resonance imaging scans were obtained in 95% of the patients (21 of 22) at a mean of 2.5 months (range, 0.3-10.2 months) postoperatively and showed graft integrity rates of 100% (21 of 21) on the tuberosity side, 76% (16 of 21) at the midsubstance, and 81% (17 of 21) on the glenoid side. No significant differences in clinical outcome scores (P > 0.930) were found in patients with intact grafts versus those with torn grafts. The number of previous shoulder surgical procedures was a negative predictor of clinical outcome. There was 1 clinical failure. SCR using DA for irreparable tears improves outcomes with high satisfaction and high graft integrity at short-term follow-up. Graft integrity, although correlated with an increased AHD, had no correlation with clinical outcomes at final follow-up. Level IV, case series.

A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty

Reverse total shoulder arthroplasty (RTSA) does not have a standard postoperative protocol. Although instability is a worrisome complication, prolonged immobilization may also be disabling in the elderly population. This study aimed to determine if early vs. delayed range of motion (ROM) after RTSA affected postoperative ROM, patient-reported outcomes, and the dislocation rate. A single-blinded, randomized controlled trial was performed enrolling patients from 2013 to 2017. Patients were randomly assigned to either a delayed-rehabilitation group (no ROM for 6 weeks) or early-rehabilitation group (immediate physical therapy for passive and active ROM) and followed up for a minimum of 1 year. Demographic characteristics, ROM, American Shoulder and Elbow Surgeons (ASES) scores, and complications were recorded. Of an initial enrollment of 107 shoulders, 80.3% completed 1-year follow-up: 44 shoulders in the delayed-therapy group and 42 shoulders in the immediate-therapy group. Both groups had significantly improved forward flexion (32° improvement) and abduction (22° improvement) by 3 months. Both groups showed significant improvements in ASES scores by 6 weeks (9.4-point improvement in composite score) with continued improvement through 6 months (35.1 points). No significant differences were found between groups for any postoperative measure, with the exception of the ASES functional score favoring the delayed-therapy group at 6 months (26.3-point improvement vs. 16.7-point improvement). No differences in complications, notching, or narcotic use were noted between groups. Both early- and delayed-ROM protocols after RTSA demonstrated significant, similar improvements in ROM and outcomes. Early initiation of postoperative rehabilitation may benefit the elderly population by avoiding the limitations of prolonged immobilization postoperatively.

High Clinical Failure Rate After Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears

To evaluate the clinical success rate, along with risk factors for failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears. We performed a retrospective chart review of prospectively collected data from an institutional shoulder outcome registry. All patients who underwent latissimus dorsi transfer for previously failed rotator cuff repair between 2006 and 2013 with a minimum follow-up period of 1year were included in the study. The indications for inclusion were large (≥2 tendons), retracted, chronic rotator cuff tears with fatty infiltration or atrophy for which prior surgical repair had failed. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores were collected, along with postoperative Single Assessment Numerical Evaluation scores. Complications and clinical failures (Δ in ASES score <17) were recorded. Patient demographic and tear characteristics were evaluated as potential risk factors for failure. A total of 22 patients (mean age, 53 ± 6years) were included in the study, with a mean follow-up time of 3.4 ± 1.1years. Over 63% of patients (n= 14) reported undergoing 2 or more prior failed rotator cuff repairs. Patients undergoing latissimus dorsi transfer showed significant improvements in ASES scores (from 35.2 ± 21.9 preoperatively to 55.8 ± 22.9 postoperatively, P= .001), Simple Shoulder Test scores (from 3.5 ± 3.1 preoperatively to 5.2 ± 3.4 postoperatively, P=.002), and pain scores (from 5.9 ± 2.8 preoperatively to 4.6 ± 4.3 postoperatively, P= .002) at final follow-up. The complication rate after latissimus transfer was 27%. The rate of revision to reverse total shoulder arthroplasty was 13.6% (n= 3) after a mean of 2.7years, and the clinical failure rate was 41% (n= 9) at final follow-up. An acromiohumeral interval of less than 7mm(P= .04) and high-grade fatty infiltration (grade 3 or greater, P= .004) were significant preoperative risk factors for clinical failure. Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7mm and high-grade fatty infiltration being associated with postoperative failure. Level IV.

Superior Capsular Reconstruction for the Operatively Irreparable Rotator Cuff Tear: Clinical Outcomes Are Maintained 2 Years After Surgery

To evaluate the results of arthroscopic superior capsular reconstruction (SCR) after 2-year minimum follow-up and to compare the results with those seen in a previously studied group of patients at 1year postoperatively. The retrospective study period was October 2014 through September 2016. Inclusion criteria were arthroscopic dermal allograft SCR performed for operatively irreparable posterosuperior rotator cuff tear with intact or repairable subscapularis tendon, failure of nonoperative treatment, and clinical follow-up at 1 and minimum 2years postoperatively. Patients lost to follow-up or undergoing revision of the SCR were excluded from the analysis. The primary outcome measure was American Shoulder and Elbow Surgeons (ASES) score (mean, [95% confidence interval], P value). Secondary outcomes included visual analog pain rating (0-10), subjective shoulder value, and active forward elevation and external rotation (degrees). Radiographic analysis included acromiohumeral interval (millimeters) and graft integrity 1-year postoperation. Complications and reoperations were reviewed from the medical record. Forty-one patients met inclusion criteria at mean 34months postoperatively, and 8 were excluded. ASES score improved from 52 (46-57) preoperative to 90 (87-92; P < .0001) and 89 (86-92; P < .0001) at 1-year postoperation and at final follow-up without diminishing in the interim (P= .9). All secondary clinical outcomes improved from preoperative to final follow-up. Subjective shoulder value diminished 5% between 1year and final follow-up (P= .03), whereas active external rotation improved 11° during this time (P= .02). In total, 85% of grafts were fully healed, with acromiohumeral interval improved from 7 (6-8) mm to 8mm (7-9; P= .04). There were 2 (5%) revisions and 6 (14%) failures to reach the minimally clinically important improvement in ASES score: a 19% rate of unsatisfactory outcomes. There was an additional 1 reoperation (2%) and 1 (2%) medical complication. Arthroscopic joint preservation surgery for massive, operatively irreparable posterosuperior rotator cuff tears with dermal allograft SCR and associated procedures results in improved clinical outcomes that are durable between 1 and minimum 2-year follow-up. IV retrospective case series.

Clinical Outcomes After Reverse Shoulder Arthroplasty With and Without Subscapularis Repair: The Importance of Considering Glenosphere Lateralization

Recent biomechanical data suggests that repairing the subscapularis during reverse shoulder arthroplasty (RSA) can increase the force required by the posterior rotator cuff and deltoid to elevate the arm. We retrospectively studied patients who underwent primary RSA and had baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) shoulder scores, stratified them according to subscapularis management, then subgrouped them according to lateralization of the glenosphere component. Patients with subscapularis repair and a lateralized glenosphere had significantly less improvement in ASES scores than did those without lateralization (P = 0.016) and patients without subscapularis repair (P = 0.006). Individually, subscapularis management (P = 0.163) and glenosphere lateralization (P = 0.847) had no significant effect on the change in ASES score but in combination did have a significant effect on the change in ASES score (P = 0.002). The combination of subscapularis repair and glenosphere implant lateralization in RSA translates to significantly less clinical improvement. Patients who underwent both subscapularis repair and glenosphere lateralization had significantly less improvement in ASES scores. Level III.