Postoperative American Shoulder And Elbow Surgeons Scores Research Articles

The Suprascapular Artery as a Reference for the Evaluation of Supraspinatus Fatty Infiltration on Magnetic Resonance Imaging.

Fatty infiltration (FI) of the supraspinatus is commonly seen in chronic large-to-massive rotator cuff tears. Evaluating FI in patients with severe muscle atrophy can be confusing. The purpose of this study was to investigate the anatomic relationship between the suprascapular artery and supraspinatus muscle on magnetic resonance imaging (MRI) to provide a method for defining the border of the supraspinatus muscle on Y-view MRI. It was hypothesized that the branches of the suprascapular artery would encircle the supraspinatus muscle on Y-view and adjacent MRI slices and could be used for defining the supraspinatus outline on oblique sagittal images. Cohort study (diagnosis); Level of evidence, 3. A total of 172 shoulders that had undergone arthroscopic repair for large-to-massive rotator cuff tears were retrospectively included. Two methods, one based on the supraspinous fossa and trapezius (SF method) and the other based on the region bounded by the branches of the suprascapular artery (SA method), were used for defining the supraspinatus outline on Y-view MRI for the assessment of FI. Preoperative supraspinatus FI grade and tangent sign and postoperative tendon integrity were evaluated. Shoulder function was assessed using the American Shoulder and Elbow Surgeons (ASES) score and active range of motion. The branches of the suprascapular artery encircled the supraspinatus in all shoulders, with the diameter of the branches ranging from 0.5 to 3 mm. The agreement in supraspinatus FI grading between the SF and SA methods was 65.12%. When limited to the 61 shoulders with a positive tangent sign, the agreement dropped to 22.95% (κ = 0.032). The group (FI grade 2 by SA method and ≥3 by SF method) showed no significant difference in postoperative outcomes compared with the 2-vs-2 group but had significantly better postoperative ASES scores (P = .001) and active range of motion in forward elevation (P = .020) compared with the ≥3-vs-≥3 group. The tangent sign was positive in 92.16% of the 2-vs-≥3 group. The suprascapular artery is a reliable reference for the evaluation of supraspinatus FI. When a positive tangent sign presents, supraspinatus FI is likely to be overestimated if the hyperintensity outside the region bounded by the branches of the suprascapular artery is mistaken as FI.

Return to Sports and Activities after Arthroscopic Treatments for Rotator Cuff Lesions in Young Patients Less Than 45-Years-Old: A Systematic Review.

Background: To evaluate the outcomes of arthroscopic treatment of rotator cuff tear (RCT) in individuals under 45 years, focusing on their ability to return to sports (RTS) and work, along with different patient-reported outcomes (PROMs). Methods: Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, this systematic review encompassed articles that studied the outcomes of arthroscopic treatment of RCT in the young population (those under 45 years old). The literature search was conducted in PubMed/Medline and EMBASE until 21 May 2024. The primary outcome was the RTS, with secondary outcomes including the return to work and various PROMs. These PROMs included the American Shoulder and Elbow Surgeons (ASES) score and 10 other PROMs. Results: Out of 6267 articles, 15 met the inclusion criteria, involving 659 patients, predominantly male athletes with a weighted mean age of 28.3 years. The RCT etiology (14 studies) was primarily traumatic (72.3%), followed by chronic microtrauma in overhead athletes (16.8%) and non-traumatic (10.9%). The RTS rate (12 studies) varied between 47% and 100%, with a cumulative rate of 75.2%. The cumulative rate of return to the same or higher RTS level (11 studies) was 56.1%. Excluding non-athletes and patients treated with debridement, the RTS rates increased to 79.8% (143/179) overall, with a 61% (108/177) rate of returning to the same or higher level. The return to work (3 studies) was successful in 90.6% of cases. Postoperative ASES scores (5 studies) improved markedly to a weighted post-operative mean of 75.6, with similar positive trends across other PROMs. Conclusions: Young adults undergoing arthroscopic RCT repair typically experience a 75% RTS rate at any level, and 56.1% RTS at the same level. Excluding non-athletes and debridement patients, RTS rates rise to 79.8% (143/179), with 61% (108/177) achieving the same or higher level. Level of evidence: IV, systematic review including case series.

Reconstruction of recurrent shoulder dislocation with glenoid bone defect with 3D-printed titanium alloy pad: outcomes at 2-year minimum follow-up

BackgroundTo evaluate the outcome of shoulder arthroscopy-assisted implantation of three-dimensional (3D)-printed titanium pads for recurrent shoulder dislocation with glenoid bone defects.MethodsFrom June 2019 to May 2020, the clinical efficacy of 3D printed titanium pad implantation assisted by shoulder arthroscopy, for the treatment of recurrent shoulder dislocations with shoulder glenoid defects was retrospectively analyzed. The American Shoulder and Elbow Surgeons (ASES) shoulder, Rowe, and Constant scores were recorded before surgery and at 3 months, 6 months, 1 year, and 2 years after surgery. 3D computed tomography (CT) and magnetic resonance imaging were used to evaluate the location of the glenoid pad, bone ingrowth, joint degeneration, and osteochondral damage.ResultsThe mean age of the 12 patients was 21.4 (19–24) years and the mean follow-up time was 27.6 (24–35) months. The Visual Analog Scale score significantly improved from 5.67 ± 1.98 preoperatively to 0.83 ± 0.58 postoperatively (p = 0.012). The postoperative ASES score was significantly increased to 87.91 ± 3.47 compared with preoperative ASES score (46.79 ± 6.45) (p < 0.01). Rowe and Constant scores also improved from 22.5 ± 12.34 and 56.58 ± 7.59 preoperatively to 90.83 ± 4.69 and 90.17 ± 1.89 at 2 years postoperatively, respectively. CT performed 2 years after surgery showed that the pad perfectly replenished the bone-defective part of the shoulder glenoid and restored the articular surface curvature of the shoulder glenoid in the anterior-posterior direction, and the bone around the central riser of the pad was tightly united. Magnetic resonance imaging 2 years after surgery showed that the humeral head osteochondral bone was intact, and there was no obvious osteochondral damage.Conclusions3D printed titanium pads are a reliable, safe, and effective surgical procedure for treating recurrent shoulder dislocations with glenoid bone defects.

Outcomes of scapulothoracic fusion in patients with facioscapulohumeral dystrophy: a comparison of allograft versus autograft bone grafting.

Scapulothoracic (ST) fusion for facioscapulohumeral muscular dystrophy (FSHD) is an established treatment that corrects scapular instability, although it has high reported complication rates. The purpose of our study was to characterize the outcomes of ST fusion for FSHD in a large patient cohort and compare the outcomes based on bone graft type and fixation technique. Our hypothesis was that union rates would not differ by bone graft type during ST fusion. A retrospective chart review was undertaken to identify patients who underwent ST fusion at multiple institutions performed by a single surgeon between 2013 and 2019 with minimum 2-year follow-up. Patient demographic characteristics, surgical technique, time to union, complications, and clinical outcomes including patient-reported outcome measures were recorded. Univariate and multivariate statistical analyses including regression analyses were performed to compare preoperative and postoperative outcomes. A total of 50 patients with 54 ST fusions (bilateral in 4 patients) and an average follow-up period of 5.8 years (standard deviation, 1.6 years) were included for analysis. Active forward elevation (77° vs. 124°, P<.00001) and abduction (60° vs. 90°, P<.00001) both improved significantly after fusion. Average internal rotation after fusion was at spinal level L3-L4. The visual analog scale pain score (2.6 vs. 1.2, P<.00001), Subjective Shoulder Value score (33 vs. 76, P<.00001), and American Shoulder and Elbow Surgeons (ASES) score (41.8 vs. 76.1, P<.00001) all improved significantly postoperatively. Of the shoulders, 50% (27 of 54) received treatment with cerclage wires and 50% (27 of 54) received treatment with Luque wires. Femoral head allograft was used in 53.7% of shoulders (29 of 54), whereas iliac crest autograft was used in 46.3% (25 of 54). Average radiographic time to healing was 11.1 weeks (standard deviation, 3.2 weeks), with no incidence of nonunion, and did not significantly differ by bone graft type (P=.26) or technique (P=.20). The complication rate was 24.1%, including seroma (n=3), superficial infection (n=2), transient neurologic injury (n=2), hemothorax (n=1), rib fracture (n=1), pneumothorax (n=1), and shortness of breath (n=1), although none requiring reoperation. There was no significant difference in the rate of postoperative complications when compared by surgical technique (P=.81) and bone graft type (P=.93). There were no independently predictive factors influencing the rate of postoperative complications by multivariate regression. Regression analysis showed that the postoperative ASES score was independently associated with the preoperative ASES score (P<.0001), use of iliac crest autograft (P<.011), and presence of complications (P<.043). Patients receiving ST fusion for FSHD demonstrate globally improved active motion and patient-reported outcome measures. Fusion construct or type of bone graft does not affect time to union or complication rates. Surgeons should be aware of a relatively high complication rate in the early postoperative period.

Superior capsular reconstruction using the long head of the biceps to treat massive rotator cuff tears improves patients shoulder pain, mobility and function.

Arthroscopic superior capsule reconstruction (SCR) with the long head of the biceps (LHBT) was performed to restore structural stability, force couple balance, and shoulder joint function. This study aimed to evaluate the functional outcomes of SCR using the LHBT over at least 24months of follow-up. This retrospective study included 89 patients with massive rotator cuff tears who underwent SCR using the LHBT, met the inclusion criteria and underwent follow up for at least 24months. The preoperative and postoperative shoulder range of motion (forward flexion, external rotation, and abduction), acromiohumeral interval (AHI), visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score were obtained, and the tear size, and Goutallier and Hamada grades were also investigated. Compared with those measured preoperatively, the range of motion, AHI, and VAS, Constant-Murley, and ASES scores were significantly improved immediately postoperatively (P < 0.001) and at the 6-month, 12-month, and final follow-ups (P < 0.001). At the last follow-up, the postoperative ASES score and Constant-Murley score increased from 42.8 ± 7.6 to 87.4 ± 6.1, and 42.3 ± 8.9 to 84.9 ± 10.7, respectively; with improvements of 51 ± 21.7 in forward flexion, 21.0 ± 8.1 in external rotation, and 58.5 ± 22.5 in abduction. The AHI increased 2.1 ± 0.8mm and the VAS score significantly changed from 6.0 (5.0, 7.0) to 1.0 (0.0, 1.0), at the final follow-up. Eleven of the 89 patients experienced retears, and one patient needed reoperation. In this study with at least 24-months of follow-up, SCR using the LHBT for massive rotator cuff tears could effectively relieve shoulder pain, restore shoulder function and increase shoulder mobility to some extent. IV.

Low resilience is associated with decreased patient-reported outcomes following arthroscopic rotator cuff repair

<h2>Abstract</h2><h3>Background</h3> The purpose of this study was to evaluate the relationship between preoperative resiliency and outcomes following arthroscopic rotator cuff repair (ARCR). The hypothesis was that patients with low preoperative resilience would have poorer postoperative patient reported outcomes compared to patients with high preoperative resilience following ARCR. <h3>Methods</h3> Eighty-one consecutive patients undergoing ARCR over a 1 year period at a single institution were prospectively evaluated. Baseline evaluation included a Brief Resilience Scale (BRS), range of motion, and the following patient-reported outcomes (PROs): visual analog scale pain (VAS), the American Shoulder and Elbow Surgeons (ASES), Veterans RAND 12-Item Health Survey (VR-12), and the Single Assessment Numeric Evaluation (SANE) tests. PROs and range of motion were reassessed at a minimum of 2 years postoperatively. Patients were divided based on the baseline BRS score into low-resilience (LR), normal-resilience (NR), and high-resilience (HR), and outcome scores were calculated for each group. Additionally, a regression analysis was performed to evaluate predictors of the final ASES score as a continuous variable. <h3>Results</h3> Despite similar baseline characteristics and postoperative range of motion and VAS scores, patients with LR had poorer postoperative ASES scores compared to patients with HR. The postoperative ASES score was 69 in the LR group, compared to 90 in the HR group (p =.031). Satisfaction was 78% in the LR group, compared to 100% in the HR group (p =.086). Based on regression analysis, the final ASES score increased 1.6 points for every 1-point increase in resilience. <h3>Conclusion</h3> Preoperative low resilience is associated with an over 20-point drop in postoperative ASES scores following ARCR. This difference is present despite similar baseline characteristics, suggesting the psychological contribution to postoperative outcomes is substantial.

Mid- to long-term clinical outcomes after press-fit short stem reverse shoulder arthroplasty

To date, a limited number of studies report mid- to long-term outcomes of press-fit short stem shoulder arthroplasty. The purpose of this study was to report and analyze mid- to long-term outcomes in a series of patients that received press-fit short stem reverse shoulder arthroplasty (RSA). The hypothesis was that press-fit short stem RSA would be a safe and effective treatment with satisfactory mid- to long-term outcomes. The authors retrospectively reviewed the records of 60 patients that received RSA using press-fit uncemented short humeral stems by two surgeons between March 2014 and December 2015. The absolute Constant Score (CS), age-/sex-adjusted CS, and the American Shoulder and Elbow Surgeons (ASES) score were recorded preoperatively and postoperatively at a minimum follow-up of 6 years. The proportions of patients that achieved a satisfactory outcome after RSA were based on the substantial clinical benefit, as proposed for the absolute CS (net improvement ≥19.1). Of the initial cohort of 60 patients, 9 (15%) died of causes unrelated to RSA, 5 (8%) were revised with partial implant removal, and 4 (7%) were lost to follow-up. This left a final cohort of 42 patients (70%) with complete postoperative CS (absolute and age-/sex-adjusted) and ASES scores at a mean follow-up of 6.7±0.5 years (range, 6.1-7.8). Of the final cohort, 11 (18%) had complications, of which 9 (15%) were treated conservatively, and 2 (3%) required reoperations without implant removal. Net improvements in functional outcomes were 34.7±21.2 for the absolute CS, 54%±32% for the age-/sex-adjusted CS, and postoperative ASES scores were 87.9±13.7. Of the 29 patients who had complete records for absolute CS, 22 (76%) received a substantial clinical benefit (net improvement ≥19.1). Mean net improvements of absolute CS exceeded the substantial clinical benefit after press-fit short stem RSA at a follow-up of 6.1 to 8.6 years. While 5 patients (8%) experienced postoperative instability, none had fracture sequelae, which indicates that offset or angular adjustments may be required even in patients with normal bony anatomy. Press-fit short stem RSA is a safe and effective treatment with satisfactory mid- to long-term outcomes, with no stem revisions for aseptic reasons, which compares favorably to the literature that reports high rates of osteolysis and subsequent stem loosening.

Effect of total arthroscopic rotator cuff repair on pain degree and complications of elderly patients with rotator cuff injury within 72 hours after operation

To analyze the clinical effect of rotator cuff repair and small incision rotator cuff repair under the total arthroscopy in elderly patients with rotator cuff injury. A total of 60 elderly patients with rotator cuff injury from January 2017 to November 2018 were selected as the research objects, including 37 males and 23 females;aged from 61 to 77 years old with an average of (63.45±12.34) years old;disease duration ranged from 6 to 12 months, with an average of (5.32±1.02 ) months;29 cases on the left side and 31 cases on the right side. Among them, 30 patients underwent total arthroscopic rotator cuff repair (observation group), 30 patients underwent small-incision rotator cuff repair(control group). The scores of University of California, Los Angeles(UCLA) shoulder rating scale, before and after surgery in the two groups were observed and recorded. The American Shoulder and Elbow Surgeons(ASES) score, Constant-Murley score, shoulder flexion range of motion, external rotation range of motion, abduction range of motion, visual analogue scale(VAS) within 72 hours after surgery, as well as the complcations were compared. The postoperative UCLA score, ASES score and Constant-Murley score between two groups were significantly higher than those before operation (P<0.05). There was no significant difference in postoperative UCLA, ASES and Constant-Murley score between two groups (P>0.05). The shoulder flexion range of motion, external rotation range of motion and abduction range of motion between two groups were significantly higher than those before operation (P<0.05). There was no significant difference between the two groups after operation (P>0.05). The VAS at 24, 48 and 72 h after operation in observation group were significantly lower than those in control group (P<0.05). The total incidence of complications in observation group(13.33%, 4/30) was sinificantly lower(P<0.05)than that in control group(33.33%, 10/30). Total arthroscopic rotator cuff repair and small incision rotator cuff repair can improve the shoulder function after rotator cuff injury in elderly, but the degree of pain and complications within 72 hours after total arthroscopic rotator cuff repair are significantly better than small incision rotator cuff repair, which can be selected according to the clinical situation and needs of patients.

Poster 151: Latarjet Treatment of Anterior Shoulder Instability: The Effect of Pre-Operative MRI Coracoid Dimensions on Post-Operative Outcomes

Objectives:While pre-operative coracoid dimensions have been previously evaluated utilizing CT, no studies have utilized MRI to evaluate coracoid dimensions before Latarjet surgery. Also, no studies have evaluated post-operative outcomes based on pre-operative coracoid dimensions in Latarjet patients. Therefore, the purpose is to determine the effect of coracoid length and width as measured on pre-operative imaging (MRI) on outcomes following Latarjet treatment of anterior shoulder instability. We hypothesized that patients with longer and wider coracoid dimensions would have improved post-operative outcomes after Latarjet treatment for anterior shoulder instability.Methods:Patients who underwent primary Latarjet surgery between 2009-2019 were identified. Inclusion criteria were an available pre-operative MRI and minimum of 2-year post-operative follow-up. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Width measurements were obtained perpendicular to length at three locations – the coracoid base, midpoint and tip – and then averaged. Inter-rater reliability was good for measuring both coracoid length (ICC=0.75) and coracoid width (ICC=0.76). The primary outcomes of interest were recurrent instability, re-operation, complications, rate of and time until return-to-sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Comparisons were made between shorter vs. longer coracoid length, narrower vs. wider coracoid width, and male vs. female coracoid dimensions.Results:56 patients were included with an average age of 28.4 years and 16% were female. There were no statistically significant demographic differences between coracoid length and coracoid width groups. Coracoid length averaged 21.6 ± 2.4 mm (range: 16.7-26.9 mm), coracoid width 10.0 ± 1.0 mm (range: 8.3-13.2 mm), and glenoid bone loss 13.7% ± 8.2% (range: 0.0%-32.4%). There were 41 patients (73.2%) with harvestable coracoid length ≥ 20 mm. 55 patients received two coracoid screws for fixation, and only one patient was limited to one screw. Patients with a smaller coracoid length (<22 mm, n=30) had similar rate of recurrent instability (smaller length 6.7% vs. longer length 3.8%), complication (10.0% vs. 15.4%), re-operation (3.3% vs. 7.7%), rate of RTS (76.5% vs. 58.8%), and post-operative ASES scores (85.0 vs. 81.6) (all p>0.05), relative to patients with a larger coracoid length (>22 mm, n=26). Likewise, patients with a smaller coracoid width (<10 mm, n=29) had similar prevalence of recurrent instability (smaller width 6.9% vs. larger width 3.7%), complication (17.2% vs. 7.4%), re-operation (3.5% vs. 7.4%), rate of RTS (66.7% vs. 68.4%), and post-operative ASES scores (87.1 vs. 80.0) (all p>0.05), relative to patients with a larger coracoid length (>10 mm, n=27). Finally, male patients had a larger average coracoid width (10.1 ± 1.0 mm) than female patients (9.3 ± 0.5 mm) (p=0.001).Conclusions:This MRI protocol closely accounts for the specific landmarks utilized during the Latarjet osteotomy by focusing on identification of the CC ligament insertion. A minimum pre-operative coracoid length of 25 mm is not needed as previously stated, as anterior shoulder instability patients experience favorable post-operative outcomes after Latarjet surgery regardless of pre-operative coracoid dimensions based on our findings. Surgeons who are treating patients with significant glenoid bone loss may utilize this MRI protocol if they are concerned about the anatomy of the coracoid pre-operatively.Figure 1.Demonstration of coracoid width measurements. (Figure 2A) First, on the coronal T1 weighted oblique sequence the coracoclavicular ligaments were identified (between the red arrows), outlined by fat, including the more medial trapezoid ligament and lateral conoid ligament. (Figure 2B) Using scout localizers, the insertion of the coracoclavicular ligaments on the fluid sensitive axial sequence was identified (red arrow). A line from this point to the anterior margin of the glenoid was drawn (yellow dotted line) denoting the width of the coracoid base. Coracoid width measurements were then collected at three locations: 5 mm anteriorly from the coracoid base, midpoint, and 5 mm posteriorly from the coracoid tip. A straight line from the midpoint of the base to tip (not shown) was drawn to approximate coracoid length.Figure 2.Difference between mean pre-operative coracoid length (on left) and width (on right) between female (dark) and male (not dark) patients as measured on MRI. UPLOAD-https://planion-client-files.s3.amazonaws.com/AOSSM/blobs/d06d5b2e-8ec8-40b2-a9b0-fd58358533b7/1/Table_2_Coracoid_Dimensions.doc Table 1.Comparison of post-operative complications, recurrent instability, and re-operation between smaller (<22 mm) and larger (≥22 mm) coracoid length, and between smaller (<10 mm) and larger (≥10 mm) coracoid width. Categorical data presented as n (%), continuous data presented as mean ± standard deviation.Table 2.Comparison of post-operative American Shoulder and Elbow Surgeons (ASES) scores, return to play (RTP) rates, and RTP time between smaller (<22 mm) and larger (≥22 mm) coracoid length, and between smaller (<10 mm) and larger (≥10 mm) coracoid width. Categorical data presented as n (%), continuous data presented as mean ± standard deviation.

Superior Capsular Reconstruction Versus Lower Trapezius Transfer for Posterosuperior Irreparable Rotator Cuff Tears With High-Grade Fatty Infiltration in the Infraspinatus

Background: Superior capsular reconstruction (SCR) and lower trapezius transfer (LTT) have recently been utilized to treat irreparable rotator cuff tears (IRCTs). There is still no clear guideline on which treatment method is a better fit for posterosuperior IRCTs with high-grade 4 fatty infiltration in the infraspinatus. Purpose: To compare the clinical and radiological outcomes between arthroscopic-assisted SCR (aSCR) and arthroscopic-assisted LTT (aLTT) in patients with posterosuperior IRCTs with high-grade (Goutallier grade 4) fatty infiltration in the infraspinatus muscle. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study included patients who underwent aSCR or aLTT for posterosuperior IRCTs with high-grade 4 fatty infiltration in the infraspinatus and had a minimum follow-up of 2 years between 2017 and 2019. A total of 58 patients were divided into 2 groups according to the surgical procedure: aSCR group (n = 22) and aLTT group (n = 36). Clinical outcomes comprised the visual analog scale score for pain, active shoulder range of motion (ROM), the American Shoulder and Elbow Surgeons (ASES) score, and patient satisfaction. Radiological outcomes comprised the acromiohumeral distance (AHD). The progression of arthritis was evaluated via the Hamada grade. Graft integrity was assessed on postoperative magnetic resonance imaging scans. Results: Significant improvements in clinical outcomes were observed in both groups. However, active shoulder ROM (forward elevation: 165.7°± 22.3° vs 145.5°± 32.3°, respectively [P = .015]; external rotation: 51.7°± 10.9° vs 41.1°± 7.0°, respectively [P < .001]), the postoperative ASES score (84.8 ± 7.6 vs 76.8 ± 20.3, respectively; P = .045), and patient satisfaction (8.9 ± 1.2 vs 6.4 ± 2.1, respectively; P = .041) were significantly higher with aLTT than with aSCR. There was no significant difference between the groups in AHD at 2 years postoperatively. However, the rate of progression of arthritis was significantly higher with aSCR (22.7%) than with aLTT (2.8%) (P = .027). Moreover, the graft retear rate was significantly higher with aSCR (63.6%) than with aLTT (8.3%) at 2 years postoperatively (P < .001). Conclusion: Although aSCR and aLTT both provided improvements in overall clinical outcomes for posterosuperior IRCTs with high-grade 4 fatty infiltration in the infraspinatus, aLTT was superior in terms of functional improvement, patient satisfaction, progression of arthritis, and graft integrity. Therefore, we prefer aLTT for posterosuperior IRCTs under the condition of high-grade 4 fatty infiltration in the infraspinatus.

Clinical and radiographic results of eccentric glenoid reaming in reverse total shoulder arthroplasty

BackgroundOne option for treating glenoid bone loss in reverse shoulder arthroplasty (RSA) is eccentric reaming of the glenoid, but the effect on clinical results is unclear. The aim of this study was to investigate the association between medialization of the bone-baseplate interface (herein, ‘medialization’) caused by eccentric reaming of the glenoid and scapular notching, baseplate loosening, and clinical outcomes after RSA. MethodsWe retrospectively reviewed data for 91 patients who underwent primary RSA between January 2014 and December 2016 with a lateralized implant and a minimum 2-year follow-up. The amount of medialization was estimated using a 3-dimensional computed tomography scan-based computer planning software. The average amount of medialization estimated by the 3-dimensional planning software was 3.4 mm (range, 0.5-10 mm). Outcomes included range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, visual analog scale (VAS) for pain, and the rates of scapular notching and baseplate loosening. The association between the estimated medialization and the outcomes of interest was evaluated using multivariate models. ResultsAfter controlling for age, sex, diagnosis, subscapularis repair, glenosphere size, and baseline ROM, medialization was not associated with the postoperative abduction (P = .35), external rotation (ER) at 90° (P = .16), internal rotation at 90° (P = .08), and internal rotation at the back (P = .06). However, we found a significant association between medialization and postoperative ER at the side (P = .02). According to the multivariate model, for a 1-mm increase in medialization during surgery, a decrease of 1.6° in postoperative ER would be expected. We found no association between medialization and the postoperative ASES score (P = .48), SST score (P = .59), or VAS score (P = .27). At a minimum of 2 years of follow-up, we found no baseplate loosening or radiographic signs of baseplate loosening in any patient. Scapular notching of grades 1 to 2 was observed in 22 patients (24%). We were not able to detect a difference in scapular notching when medialization was > 1 mm ver when medialization ≤ 1 mm (odds ratio, 2.5; 95% confidence interval: 0.28-23). ConclusionsIncreasing medialization due to eccentric reaming after RSA with a lateralized implant was associated with a decrease in postoperative ER at the side. However, increasing medialization was not associated with worse patient-reported outcome scores or increased baseplate loosening at short-term follow-up.

Clinical Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Primary Glenohumeral Osteoarthritis Compared With Rotator Cuff Tear Arthropathy: Does Preoperative Diagnosis Make a Difference?

The primary purpose of this study was to evaluate the clinical outcomes of patients who underwent reverse total shoulder arthroplasty performed for primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff compared with rotator cuff tear arthropathy (CTA). This was a retrospective review of prospectively collected data including consecutive patients who underwent primary reverse total shoulder arthroplasty for GHOA or CTA with a minimum of 2-year follow-up. Baseline patient demographics and clinical outcomes including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation, and visual analog scale for pain were collected. Univariate and multivariate regression analyses were performed to evaluate the effect of preoperative diagnosis on clinical outcomes. Patients with a preoperative diagnosis of GHOA demonstrated significantly better postoperative active forward elevation (138.6° versus 127.3°; P < 0.01), external rotation (54.2° versus 43.8°; P < 0.01), and change in internal rotation (Δ 2.1 points versus Δ 1.2 points; P < 0.01). Patients with GHOA demonstrated significantly better postoperative ASES (86.8 versus 76.6; P < 0.01), Single Assessment Numerical Evaluation (89.7 versus 78.5; P < 0.01), and visual analog scale scores (0.63 versus 1.2; P < 0.01). Minimal clinically important difference for ASES score was achieved by 97.5% of patients with GHOA compared with 86.7% of patients with CTA (P < 0.01), whereas substantial clinical benefit was achieved by 90.4% of patients with GHOA and 71.7% of patients with CTA (P < 0.01). After a multivariate linear regression analysis, postoperative ASES scores were independently associated with previous ipsilateral shoulder surgery (P = 0.042), preoperative ASES score (P = 0.01), and primary diagnosis of GHOA (P < 0.01). RTSA performed in patients with GHOA and an intact rotator cuff is associated with improved functional and clinical outcomes compared with those patients treated for CTA. Level III Therapeutic Study.

Knotted Versus Knotless Medial-Row Transosseous-Equivalent Double-Row Rotator Cuff Repairs Have Similar Clinical and Functional Outcomes

PurposeTo retrospectively investigate the clinical and functional outcomes of patients who underwent knotted medial-row rotator cuff repair (KT-RCR) compared with patients who underwent knotless medial-row rotator cuff repair (KL-RCR).MethodsA retrospective chart review of patients who underwent double-row transosseous-equivalent rotator cuff repair in 2016 was performed at a single institution with 2-year follow-up. Information regarding demographic characteristics, preoperative tear size (magnetic resonance imaging), surgical variables (including method of suture stabilization), preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) scores, and all complications (e.g., cuff failure, adhesive capsulitis, and persistent pain) was compiled.ResultsA total of 189 patients met the inclusion criteria: 72 in the KL-RCR group and 117 in the KT-RCR group. No significant difference in preoperative ASES scores was found between the KL-RCR and KT-RCR groups (48.3 vs 45.4, P = .327). Postoperative ASES scores did not differ between the groups (82.4 for KL-RCR vs 78.8 for KT-RCR, P = .579). We found no significant difference in cuff failure rates after 2 years, determined by magnetic resonance imaging (5.6% for KL-RCR vs 6.1% for KT-RCR, P > .999), or complication rates (11.1% for KL-RCR vs 8.6% for KT-RCR, P = .743).ConclusionsThe knotted approach and knotless approach to double-row rotator cuff repair showed similar outcome scores, cuff failure rates, and complication rates at minimum 2-year follow-up.Level of EvidenceLevel III, retrospective therapeutic comparative trial.

Clinical outcomes and temporal changes in the range of motion following superior capsular reconstruction for irreparable rotator cuff tears: comparison based on the Hamada classification, presence or absence of shoulder pseudoparalysis, and status of the subscapularis tendon.

Superior capsular reconstruction (SCR) has recently gained popularity as a surgical solution for patients with massive rotator cuff tears or shoulder pseudoparalysis (PPS). Good clinical outcomes have been reported after SCR; however, the factors that influence its clinical outcomes remain unclear. Therefore, in this study, we aimed to clarify the factors influencing postoperative outcomes after SCR using tensor fascia lata graft, for which we evaluated the Hamada grade, patients with or without PPS, and the status of the subscapularis tendon (SSC). In total, 54 consecutive patients with irreparable rotator cuff tears or PPS who underwent SCR between June 2014 and October 2018 were included. The enrolled patients were grouped and compared as follows: (1) Hamada grade 2 (11 patients) and Hamada grade 3 (43 patients) and (2) non-PPS (22 patients), moderate PPS (16 patients), and severe PPS (16 patients). For subanalysis, the 32 PPS patients were divided into 3 groups: intact SSC (11 patients), repairable SSC (16 patients), and irreparable SSC (5 patients). To assess shoulder function, the American Shoulder and Elbow Surgeons (ASES) score was evaluated before surgery and at 24 months postoperatively; shoulder range of motion was evaluated at 2, 3, 4, 5, 6, 8, 10, 12, and 24 months postoperatively. No significant differences in postoperative ASES scores and shoulder range of motion were observed between the Hamada grade 2 and grade 3 groups or between the non-PPS, moderate PPS, and severe PPS groups. However, significant differences in postoperative shoulder elevation and ASES scores were observed between the intact SSC and irreparable SSC groups (P = .006) and between the repairable SSC and irreparable SSC groups (P = .003). This study demonstrated that the status of the SSC, rather than the Hamada grade or the presence or absence of PPS, influences the clinical outcomes after SCR. Therefore, reparability or intactness of the SSC is an important factor in considering the surgical indication for SCR.

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold. MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05. ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10). ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA. Level of EvidenceLevel III; Retrospective Comparative Treatment Study

Preoperative Fatty Infiltration of the Teres Minor Negatively Affects Postoperative Outcomes in Patients With Rotator Cuff Pathology.

Background:The teres minor is a critical component of the rotator cuff and serves as one of the few external rotators of the humerus. Information is lacking regarding the effect of teres minor atrophy in isolation and in the setting of concomitant full-thickness rotator cuff tears on outcomes in patients undergoing rotator cuff surgery.Purpose:To investigate the effect of preoperative teres minor fatty infiltration on postoperative clinical outcomes in patients with and without full-thickness rotator cuff pathology.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective review of patients undergoing primary arthroscopic shoulder surgery between 2014 and 2016 was performed. Preoperative magnetic resonance imaging was used to determine fatty infiltration for each rotator cuff muscle using the modified Goutallier classification. American Shoulder and Elbow Surgeons (ASES) as well as the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained preoperatively and during follow-up. Exclusion criteria included prior surgery on the ipsilateral shoulder or a diagnosis of inflammatory arthropathy. For analysis, patients were dichotomized to grade 0 or grade 1-4 atrophy of the teres minor as well as to full-thickness or partial-thickness rotator cuff pathology.Results:A total of 36 of 47 (76.6%) patients (mean age, 63 years; range, 45-76 years) were available for postoperative follow-up at a mean of 40 months (range, 30-48 months). Postoperative ASES score was significantly higher and QuickDASH score was significantly lower among all patients in the grade 0 group compared with the grade 1-4 group. Postoperative ASES and QuickDASH scores were not significantly different in patients with partial-thickness rotator cuff tears at any time point. However, the postoperative ASES score was significantly higher and QuickDASH score was significantly lower in the grade 0 versus grade 1-4 group for patients with full-thickness rotator cuff pathology.Conclusion:Preoperative teres minor atrophy in patients undergoing surgery for rotator cuff pathology may impair postoperative clinical outcomes, especially in patients with full-thickness tears.

Effect of Insurance Status on Clinical Outcomes After Shoulder Arthroplasty.

Shoulder arthroplasty is an effective treatment option for patients with symptomatic shoulder arthritis and rotator cuff arthropathy. Although there have been reports of variations in complication rates according to insurance type, few studies have examined the effect of payer status on functional outcomes. Patients who underwent elective shoulder arthroplasty performed by a single fellowship-trained surgeon and had a minimum of 1 year of follow-up were queried. Patient characteristics were compared across insurance types. Each patient completed the American Shoulder and Elbow Surgeons (ASES) questionnaire preoperatively and postoperatively. A generalized linear mixed model was specified to predict ASES score at 1 year and included preoperative ASES score as an adjustment variable. A total of 84 patients underwent 91 procedures. Before surgery, ASES score differed by insurance type (P=.014), with lower scores in the Medicaid cohort compared with the private insurance cohort (20.4 vs 38.8, P=.009). After controlling for baseline ASES score, postoperative ASES score at 1-year follow-up differed by insurance type (P<.001). Patients with private insurance had better ASES scores (85.6) than patients with Medicaid (55.2) (P<.001) and workers' compensation (57.1) (P=.028). Patients with Medicare (80.6) had better ASES scores at follow-up compared with those with Medicaid (P<.001). Patients with Medicaid are at risk for significantly lower postoperative functional outcome scores after shoulder arthroplasty compared with patients with private insurance and Medicare. In this study, patients with Medicaid had lower preoperative ASES scores compared with other groups. These observed differences are likely multifactorial and should be acknowledged when counseling patients. [Orthopedics. 2020;43(6):e523-e528.].

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.

Functional and MRI outcomes of Superior Capsule Reconstruction with Acellular Dermal Matrix

Objectives:Superior capsular reconstruction (SCR) is an emerging treatment option for irreparable massive rotator cuff tears (MRCT). The initial description utilized fascia lata autograft, but acellular dermal matrix (ADM) has become the graft of choice in the United States. Several reports have demonstrated excellent short-term functional improvement and patient satisfaction, but there is limited data correlating imaging studies of graft integrity to functional outcome. The purpose of this study was to determine if functional outcome after SCR is dependent on dermal allograft integrity on post-operative MRI.Methods:Inclusion criteria were patients who underwent an SCR by one of 5 fellowship-trained surgeons at a single institution for the indication of pain attributable to irreparable MRCT that failed non-operative treatment. Exclusion criteria included arthritis, prior infection, revision SCR, and less than 6 months follow-up. Pre- operative data including age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. Intra-operative data including surgical findings and concomitant procedures were recorded. Pre- and post-operative acromiohumeral distance (AHD), American Shoulder and Elbow Surgeons (ASES), Oxford, visual analogue scale (VAS) and post-operative SANE score were recorded. In 90% of cases, a 3 mm ADM was used and in 10% of cases, a 6 mm ADM was used (doubled over 3 mm graft). All grafts were fixed by a double-row, trans-osseous equivalent technique on the tuberosity and with a mean of 3 anchors on the glenoid. Patients were routinely offered to undergo an MRI postoperatively regardless of symptoms.Results:53 patients met our inclusion criteria. Mean age was 60.1+7.9 years (range 34 to 77). 68% were male; 34% had at least one prior procedure; 58% had a concomitant procedure; 57% were Hamada 1, 38% Hamada 2, and 5% Hamada 3. Pre-op Goutallier stage was 3.7% grade 0, 17% grade 1, 40% grade 2; 26% grade 3; 13% grade 4. The mean clinical follow-up was 15+7.8 months (range 6-42 months). 81% of patients underwent an MRI post-operatively. The mean time for MRI was 14+7 months (range 6 -40). MRI revealed that 38% had a completely intact graft, 33% had a tear from the glenoid, 12% had a mid-substance tear, 14% tear from the tuberosity, and 2% had complete graft absence. There was a significant improvement in ASES (37.7 to 79.5, P<0.0001), Oxford (26.3 to 44, P<0.0001), and VAS (7 vs 2.3, P<0.0001). There was no difference between pre-op and post-op AHD (7.3 mm vs 6.9mm, P=0.57). There was no association between pre-operative AHD (P=0.9), Goutallier stage (P=0.43), Hamada grade (P=0.49) with post-operative ASES scores. There was a significant correlation between graft integrity with final outcome. There was no difference in post-operative ASES score when the graft was completely intact or torn from the glenoid (P=0.39), but graft tear from the tuberosity resulted in a significantly lower ASES score (P=0.013).Conclusions:In patients who undergo SCR for MRCT, there is significant improvement in ASES, Oxford, and VAS. This improvement is seen in patients who have an intact graft, as well as those where the graft is torn from the glenoid, but not those torn from the tuberosity. This supports the concept of the graft functioning as a ”biologic tuberoplasy” preventing bone-to-bone contact between the tuberosity and acromion. Preoperative AHD, Goutallier, Hamada, gender, or age did not have an association with post-operative ASES scores.

Return to Sport After Arthroscopic Rotator Cuff Repair in Middle-Aged and Elderly Swimmers.

Background:No reports have been published on the clinical outcomes, including return to sport, after rotator cuff repair in middle-aged and elderly swimmers with rotator cuff tears.Purpose:To retrospectively investigate clinical outcomes and return to sport after arthroscopic rotator cuff repair in middle-aged and elderly swimmers.Study Design:Case series; Level of evidence, 4.Methods:Patients who underwent arthroscopic rotator cuff repair and met the following criteria were included: (1) age older than 45 years, (2) rotator cuff tears confirmed during surgery, (3) arthroscopic suture bridge rotator cuff repair, (4) primary surgery, and (5) swam more than once a week before surgery. The exclusion criteria were as follows: (1) irreparable large and massive tears, (2) shoulder instability, (3) arthritis or rheumatic disorders, or (4) less than 2-year follow-up. We investigated functional outcomes including range of motion; the University of California, Los Angeles (UCLA) score; the American Shoulder and Elbow Surgeons (ASES) score; return to swimming; and the return rates for each style of swimming. In addition, the functional outcomes and findings of magnetic resonance imaging were compared between the group with complete return and the group with incomplete or failed return.Results:A total of 32 shoulders in 31 middle-aged and elderly swimmers (5 males, 26 females) were included. The mean age was 65 years (range, 47-78 years), and the mean follow-up was 47 months (range, 24-86 months). Return to swimming was achieved in 31 (97%) shoulders at a mean of 8 months (range, 3-24 months), and complete return was achieved in 18 (56%) shoulders at a mean of 12 months (range, 3-24 months). The return rate was 97% for freestyle, 83% for breaststroke, 74% for backstroke, and 44% for butterfly stroke. Postoperative UCLA and ASES scores were significantly higher in the group with complete return than in the group with incomplete or failed return (P = .001 and .01, respectively). Postoperative forward elevation was significantly better in the complete return group (P = .01).Conclusion:This study demonstrated that 97% of elderly swimmers who underwent arthroscopic rotator cuff repair could return to swimming. The complete return rate was 56%; however, the group with incomplete or failed return showed poorer active forward elevation. Freestyle had the highest complete return rate, whereas the butterfly stroke had the lowest return rate. It may be important to achieve good active forward elevation postoperatively to return to swimming.