Postoperative External Rotation Research Articles

The effect of tuberosity healing on functional outcomes after reverse shoulder arthroplasty for proximal humerus fractures: a systematic review and meta-analysis.

This systematic review and meta-analysis compared clinical outcome measures in patients undergoing reverse shoulder arthroplasty (RSA) for proximal humerus fracture (PHF) with healed versus non-healed greater tuberosity (GT). We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines querying PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane for studies that stratified results by the GT healing status. Studies that did not attempt to repair the GT were excluded. We extracted and compared clinical outcomes including postoperative forward flexion (FF), external rotation (ER), internal rotation (IR), Constant score, and complications and revision rates. Of the included patients, 295 (78.5%) demonstrated GT healing while 81 did not (21.5%). The healed GT cohort exhibited increased postoperative FF (P < .001), ER (P < .001), IR (P = .006), and Constant score (P = .006) compared to the non-healed GT cohort. The overall dislocation rate was 0.8% with no study differentiating GT status of dislocation cases. Healing of the GT after RSA for PHF yields improved postoperative range of motion and strength, whereas patient-reported pain and function were largely not affected by GT healing indicating merit to RSA for PHF regardless of the likelihood of the GT healing.

Does preoperative forward elevation weakness affect clinical outcomes in anatomic or reverse total shoulder arthroplasty patients with glenohumeral osteoarthritis and intact rotator cuff?

This study sought to determine if preoperative forward elevation (FE) weakness affects outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for patients with rotator cuff-intact glenohumeral osteoarthritis (RCI-GHOA). A retrospective review of a single institution's prospectively collected shoulder arthroplasty database was performed between 2007 and 2020, including 333 aTSAs and 155 rTSAs for primary RCI-GHOA with a minimum 2-year follow-up. Defining preoperative weakness as FE strength ≤4.9 lb (2.2 kg), three cohorts were matched 1:1:1 by age, sex, and follow-up: weak (n=82) to normal aTSAs, weak (n=44) to normal rTSAs, and weak aTSAs (n=61) to weak rTSAs. Compared outcomes included range of motion, outcome scores, and complication and revision rates at latest follow-up. Weak aTSAs and weak rTSAs achieved similar postoperative outcome measures to normal aTSAs and normal rTSAs, respectively (P>0.05). Compared to weak rTSAs, weak aTSAs achieved superior postoperative passive (P=0.006) and active external rotation (ER) (P=0.014) but less favorable postoperative Shoulder Pain and Disability Index (P=0.032), American Shoulder and Elbow Surgeons (P=0.024), and University of California, Los Angeles scores (P=0.008). Weak aTSAs achieved the minimal clinically important difference and substantial clinical benefit at a lower rate for abduction (P=0.045 and P=0.003) and FE (P=0.011 and P=0.001). Weak aTSAs had a higher revision rate (P=0.025) but a similar complication rate (P=0.291) compared to weak rTSAs. Patients with RCI-GHOA and preoperative FE weakness obtain postoperative outcomes similar to patients with normal preoperative strength after either aTSA or rTSA. Preoperatively, weak aTSAs achieved greater ER but lower rates of clinically relevant improvement in overhead motion compared to weak rTSAs. Level of evidence: III.

Anatomic Versus Reverse Total Shoulder Arthroplasty for Primary Osteoarthritis With an Intact Rotator Cuff: A Midterm Comparison of Early Top Performers.

Several surgeons state that their best anatomic total shoulder arthroplasty (aTSA) outperforms their best reverse total shoulder arthroplasty (rTSA) when performed for rotator cuff-intact glenohumeral osteoarthritis. We identified the top-performing aTSAs and rTSAs at short-term follow-up and compared their clinical performance at midterm follow-up to validate this common claim. A retrospective review of a multicenter shoulder arthroplasty database was conducted. All shoulders undergoing primary aTSA or rTSA for rotator cuff-intact glenohumeral osteoarthritis between 2007 and 2020 were reviewed. Shoulders with a follow-up clinical visit between 2 and 3 years and a clinical follow-up of minimum 5 years were included. Two separate cohorts were identified: patients with a top 20% (1) American Shoulder and Elbow Surgeons (ASES) score and (2) Shoulder Arthroplasty Smart (SAS) score at 2 to 3 years of follow-up. Clinical outcomes including range of motion, outcome scores, and rates of complications and revision surgeries were compared at minimum 5-year follow-up. The ASES score cohort comprised 185 aTSAs (mean age 67 years, 42% female) and 49 rTSAs (mean age 72 years, 45% female). The SAS score cohort comprised 145 aTSAs (mean age 67 years, 59% female) and 42 rTSAs (mean age 71 years, 57% female). Active external rotation (ER) was greater after aTSA at midterm follow-up in both ASES and SAS score cohorts; however, preoperative to postoperative improvement was equivalent. Postoperative ER and SAS scores were greater after aTSA in both cohorts (P < 0.05); however, no other significant differences in any preoperative or postoperative clinical outcomes were present (P > 0.05), and patients achieved the minimal clinically important difference and substantial clinical benefit at similar rates for all outcomes. No difference was found in the incidence of complications and revision surgeries between top-performing aTSAs and rTSAs. Among top-performing shoulder arthroplasties at early follow-up, aTSA does not appear to outperform rTSA, except superior ER at midterm follow-up. Retrospective comparative cohort study, Level Ⅲ.

Poster 154: Arthroscopic Rotator Cuff Repair With Side-to-Side Sutures for Full-Thickness Transtendinous Supraspinatus Tears Yields Excellent Outcomes and Low Retear Rates Similar to Traditional Tendon-to-Bone Fixation at Mean Follow Up of 4 Years

Objectives: Full-thickness transtendinous supraspinatus tears involve a large portion of the tendon that remains attached to the footprint that often leaves insufficient medial tissue for tension free footprint restoration with traditional suture anchor repair. The aim of this study was to compare outcomes and failure rates for arthroscopic side-to-side suture repair for transtendinous tears to traditional double-row repair for more common tendon avulsions. We hypothesized poorer objective and subjective outcomes as well as higher retear rates for side-to-side suture repair. Methods: This was a retrospective cohort study of 18 consecutive patients with full-thickness transtendinous supraspinatus tears repaired with arthroscopic side-to-side sutures (Group 1) compared to 36 matched controls with classic tendon avulsion from the footprint repaired with double-row knotless transosseous equivalent (TOE) repairs (Group 2). All procedures were performed by a single surgeon with a minimum of 2 years follow-up. Demographics and prospectively collected patient reported outcomes (PROs) were collected including postoperative active range of motion (AROM), American Shoulder and Elbow Surgeons (ASES) score, Visual analog scale (VAS) for pain, and Subjective Shoulder Value (SSV). Failure defined as a symptomatic re-tear diagnosed on magnetic resonance imaging (MRI) or need for revision surgery was also determined. Preoperative tear size and Goutallier stage were recorded from MRIs. Results: There were no significant differences between Group 1 and Group 2 regarding mean follow-up (49 months vs. 52.4 months, p = 0.640) and age (68.7 ± 6.8 vs. 67.1 ± 9.6, p = 0.550). With respect to clinical outcomes and PROs, there were no differences in postoperative VAS for pain score (1 ± 1.54 vs 1.5 ± 2.1, p = 0.537), SSV score (92.2 ± 9.1 vs 87.1 ± 10.9, p = 0.086), or ASES score (90.8 ± 9.9 vs 83.1 ± 23.9, p = 0.377). No differences were identified for postoperative AROM forward flexion (153 ± 14 vs 156 ± 16, p= 0.194), external rotation (53 ± 6 vs 51 ± 9, p= 0.498) and internal rotation score (6.4 ± 1.8 vs 7.2 ± 1.2, p=0.244). There was no statistically significant difference in failure rates between cohorts (11.1% vs. 2.7%, p = 0.255). Regarding preoperative tear characteristics, fatty infiltration of the supraspinatus (1.2 ± 1 vs 1.5 ± 0.7, p= 0.307) and anteroposterior tear size were similar (21.3 ± 9.3 vs 24 ± 8, p = 0.322), although lower grades of fatty infiltration in the infraspinatus was present in Group 1 (0.3 ± 0.6 vs 1.1 ± 0.7, p &lt; 0.001). Conclusions: Arthroscopic side-to-side suture repair for supraspinatus tears yields excellent outcomes with low failure rates comparable to tendon-to-bone double suture anchor repair for typical avulsion type tears. Retention of the large tendon stump on the greater tuberosity with side-to-side repair also allows restoration of anatomy without undue tension in this uncommon scenario.

Limited preoperative forward flexion does not impact outcomes between anatomic or reverse shoulder arthroplasty for primary glenohumeral arthritis

BackgroundAnatomic total shoulder arthroplasty (TSA) remains the treatment of choice for primary glenohumeral osteoarthritis with an intact rotator cuff (PGHOA). However, reverse total shoulder arthroplasty (RSA) has gained popularity as a primary procedure in selected patients who may be at risk for postoperative rotator cuff dysfunction or glenoid loosening. The purpose of this study was to compare short-term outcomes between TSA and RSA in patients with PGHOA and limited preoperative forward flexion (FF). MethodsA retrospective review was performed on a multi-institutional registry of patients to identify patients aged less than 80 years undergoing TSA or RSA for PGHOA with preoperative FF ≤ 90°. Forty-five TSAs were identified and matched by age and sex to 45 patients undergoing RSA. A subset of 22 TSAs and 24 RSAs with severely limited preoperative FF of ≤ 70° was also analyzed. Range of motion including FF, external rotation and internal rotation, strength, and patient-reported outcomes including visual analog scale pain score, Western Ontario Osteoarthritis of the Shoulder index score, Veterans RAND 12 mental score, American Shoulder and Elbow Surgeons score, and Constant-Murley score were evaluated at a minimum of 2 years postoperative. ResultsNo significant differences were observed in postoperative FF, external rotation, or strength measurements between groups. The limited FF TSA group achieved significantly improved internal rotation compared to the RSA group (L2 vs. L4, P < .002). No significant differences were observed between TSA and RSA in American Shoulder and Elbow Surgeons, visual analog scale, Constant, or Single Assessment Numeric Evaluation scores (P > .05) for both the overall comparison and subset of patients with FF of ≤ 70°. However, patients in the RSA cohort showed a significantly higher return to normal sporting activities than the TSA group. ConclusionPatients aged less than 80 years with PGHOA and limited preoperative FF achieve similar postoperative range of motion and patient-reported outcomes whether treated with TSA or RSA. Therefore, limited preoperative FF does not appear to be a major determinant of outcomes for PGHOA.

Intraoperative repair of functional subscapularis during RSA by deltopectoral approach could improve internal rotation but does not prevent anterior dislocation

IntroductionThe role of the subscapularis following reverse shoulder arthroplasty (RSA) remains controversial as repair could restore adequate internal rotation and shoulder stability, but might compromise external rotation. The purpose of this multi-centre study, on a large cohort of RSAs performed using the deltopectoral approach, was to determine the effect of subscapularis preoperative status and intraoperative repair on range of motion, clinical scores and rates of complications at a minimum follow-up of 2 years. HypothesisRepair of a functional subscapularis grants better internal rotation and stability without compromising external rotation. Materials and methodsWe retrospectively reviewed records of all RSAs (n=916) performed by 14 surgeons that participated in a large national society symposium, and excluded 234 operated by the anterosuperior approach, 42 operated for rheumatoid arthritis, fractures, instability or post traumatic sequalae, and eight that had adjuvant latissimus dorsi tendon transfer (LDTT). This left 632 RSAs, in which the subscapularis was detached in 594, and repaired after detachment in 495. Patients completed pre- and postoperative Constant Score and postoperative Subjective Shoulder Value (SSV). Active forward elevation, active external rotation (ER), and active internal rotation (IR) were recorded pre- and postoperatively. Complications following RSA that required conservative treatment, reoperation without implant removal, as well as reoperation with implant removal were recorded. ResultsOf the initial cohort of 632 shoulders, 120 (19%) were lost to follow-up, 12 (2%) died due to causes unrelated to RSA, and 26 (4%) were revised with implant removal. Of the remaining 474 shoulders, 259 (55%) had a functional repaired subscapularis (Group FR), 59 (12%) had a non-functional repaired subscapularis (Group nFR), whereas 68 (14%) had a not repaired subscapularis (Group nR). Comparison of patient demographics revealed no significant differences among the three groups. Postoperative Constant Score (p=0.031) and SSV (p=0.016) were significantly different among the three groups, but effect sizes were small and not clinically relevant. Differences in postoperative ER as well as postoperative IR were not significant among the three groups: 91 (35%) gained functional IR in Group FR, 11 (19%) in Group nFR, and 13 (19%) in Group nR. Three shoulders (1.2%) reported subjective instability and 1 (0.4%) dislocated in Group FR, but none in either Groups nFR or nR. DiscussionDespite statistically significant differences in Constant Score and SSV among the three groups, the clinical relevance of these differences is negligible, so repair of functional subscapularis has little or no influence on functional outcomes. During RSA by deltopectoral approach, repair of a functional subscapularis could slightly improve internal rotation in some patients but does not compromise external rotation, forward elevation or clinical scores, while repair of a non-functional subscapularis, compared to non-repair, did not improve range of motion or clinical scores. Level of evidenceIII; retrospective comparative.

Short-term comparative outcomes of LIMA hybrid, metal-backed, and all cemented polyethylene glenoids

BackgroundThis study aims to compare short-term functional outcomes and conversion rates to reverse shoulder arthroplasty between patients who underwent total shoulder arthroplasty (TSA) using a modular metal-backed glenoid component, a hybrid glenoid component, and an all-polyethylene component. MethodsA retrospective review of individuals undergoing TSA between October 2014 and December 2020 was performed. Inclusion criteria included patients undergoing primary TSA for osteoarthritis during this time frame by 1 surgeon. Preoperative and postoperative variables included demographic information, American Shoulder and Elbow Surgeons score (ASES), and range of motion. Revision rates were also documented. Summary statistics were performed, using a 1-way analysis of variance with Tukey post hoc pairwise comparisons when the outcome reached significance. ResultsFifty-two patients were included with age averaging 68 ± 8.1 years, with body mass index of 31 ± 5.8. 54% of patients were female with 12% having diabetes and only 2% were smokers. Follow-up averaged 42 months with patients undergoing metal-backed glenoid having longer follow-up at 56.5 months (P < .001). ASES, forward elevation, and external rotation (ER) for every implant type improved significantly postoperatively (P < .001) besides internal rotation and ER within the poly group (P = .072). No difference was found between the 3 groups for preoperative and postoperative ASES scores, forward elevation, internal rotation, and ER (P > .05). Two patients within the poly group required revision due to rotator cuff tear (P = .225). ConclusionAt 2 years, functional outcomes and patient-reported outcomes are similar in all 3 glenoid groups. There were slightly higher revision rates within the all-polyethylene group. If outcomes are similar among all groups, modular implant systems may be favorable to make conversion to revision TSA easier.

Margin convergence vs. superior capsular reconstruction for massive irreparable rotator cuff tears: outcomes are equivalent unless there is preoperative pseudoparesis

Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates. This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n=28) or SCR (n=31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P<.05). Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P<.001). The MC and SCR groups had similar postoperative FF (151°±26° vs. 142°±38°; P=.325) and ER (48°±12° vs. 46°±11°; P=.284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF<90°), SCR (n=9) resulted in greater postoperative FF than MC (n=5) (141°±38° vs. 67°±24°; P=.002). Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications.

Long-Term Results of Isolated Latissimus Dorsi to Rotator Cuff Transfer in Brachial Plexus Birth Injury.

Background Brachial plexus birth injury results in deficits in strength and motion, occasionally requiring surgery to restore power to the deficient external rotators of the shoulder in these patients. This is a retrospective analysis of the long-term results of an isolated latissimus dorsi transfer to the rotator cuff in patients with brachial plexus birth injury. Methods This is a retrospective review of prospectively collected data for patients undergoing isolated latissimus dorsi transfer into the infraspinatus in addition to release of the internal rotation contracture of the shoulder with greater than 5 years' follow-up. Preoperative and postoperative shoulder elevation and external rotation were documented. Failure of surgery was defined as a return of the internal rotation contracture and a clinically apparent clarion sign. Results A total of 22 patients satisfied the inclusion criteria: 9 global palsies and 13 upper trunk palsies. The average follow-up was 11 years, ranging from 7.5 to 15.9 years. There was a trend for improved external rotation in the global palsy cohort at final follow-up ( p = 0.084). All nine global palsies maintained adequate external rotation without a clarion sign. Five of the 13 upper trunk palsies failed the latissimus dorsi transfer and subsequently required either teres major transfer and/or rotational osteotomy. In these five failures, the period from initial transfer to failure averaged 6.6 years, ranging from 3.4 to 9.5 years. Conclusion The results of this study indicate that patients with global palsy have sustained long-term improved outcomes with isolated latissimus dorsi transfer while patients with upper trunk palsy have a high rate of failure. Based on these results, we recommend isolated latissimus dorsi transfer for global palsy patients who have isolated infraspinatus weakness. Level of Evidence: Case series - Level IV.

Outcomes of Arthroscopic Latarjet as a Revision Surgery After Failed Arthroscopic Bankart Repair

Background: The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established. Purpose: To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure. Design: Cohort study; Level of evidence, 3. Methods: This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed. Results: A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group (P = .14). Patients in the revision group had a lower return to the previous level of sports participation (P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group (P = .000). Conclusion: Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected.

Anatomic vs. reverse total shoulder arthroplasty with glenoid retroversion of at least 15 degrees in rotator cuff intact patients: a comparison of short-term results

BackgroundSevere glenoid deformity has been associated with inferior outcomes and higher complication rates in shoulder arthroplasty. In patients with intact rotator cuffs, there is no clear consensus as to whether anatomic total shoulder arthroplasty (aTSA) or reverse (rTSA) shoulder arthroplasty is the optimal implant in patients with glenoid deformities. The purpose of this study was to compare outcomes of aTSA vs. rTSA in glenoid deformities with greater than 15° retroversion. MethodsA retrospective review of a large multicenter database was conducted. All patients who underwent either aTSA or rTSA with an intact rotator cuff and glenoid retroversion 15° or greater with minimum 2-year follow-up were included. Range of motion (ROM), revisions, and patient reported outcomes (PROs) including Constant score, Simple Shoulder test, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, Shoulder Pain and Disability Index), Shoulder Arthroplasty Smart score were collected for all patients pre and postsurgery. ResultsOverall, 336 patients were included with 187 receiving an aTSA and 149 rTSA. Reverse patients overall had more comorbidities (75.0% vs. 65.1%; P = .05) and were older (70.9 ± 7.0 vs. 66.3 ± 7.7 years; P < .001). Average follow-up for the aTSA group was 62.0 ± 37.8 months vs. 40.6 ± 22.9 months for rTSA (P < .001). Preoperative retroversion in the anatomic group averaged 20.7 ± 5.5 degrees vs. 24.2 ± 7.7 in reverse patients (P < .001). Both groups demonstrated significant improvements in all PROs and ROM from pre to postsurgery. At latest follow-up aTSA patients had significantly better internal rotation scores (4.9 ± 1.6 vs. 4 ± 1.8; P < .001), external rotation (50 ± 19 vs. 38 ± 18; P < .001) and Shoulder Arthroplasty Smart scores (80.2 ± 13.5 vs. 76.6 ± 11.3; P = .017) but worse pain VAS (1.5 ± 2.3 vs. 0.9 ± 1.9; P = .016). There was no significant difference in abduction or forward elevation or PRO’s (Shoulder function, Simple Shoulder test, Constant, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, or Shoulder Pain and Disability Index). Overall revision rate (7% vs. 1%; P = .002) was higher in aTSA. ConclusionATSA and rTSA results in significant improvements in patients with glenoid retroversion equal or greater than 15°. Anatomic TSA patients have better postoperative internal rotation score, external rotation, and SAS score but demonstrated no other significant improvement in ROM or PRO. However, there was significantly higher rate of complications and revisions with short-term follow-up following aTSA.

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

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

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

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

Radiologic and clinical outcomes of an arthroscopic bridging graft for irreparable rotator cuff tears with a modified MasonAllen stitch using a plantaris tendon autograft: a case series with minimum 2-year outcomes.

Surgical management of a massive rotator cuff tear (RCT) is always challenging. This study describes the clinical and radiological outcomes of patients who underwent bridging grafts using a plantaris tendon for an irreparable RCT. Thirteen patients with a massive RCT were treated with arthroscopic interposition of a folded plantaris tendon autograft between June 2017 and January 2020. For clinical evaluation, a visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, Constant-Murley score, and range of motion values were collected. For radiographic evaluation, standardized magnetic resonance imaging and ultrasonography were performed to check the integrity of the interposed tendon. A statistically significant improvement at the final follow-up was evident in scores for the VAS (-3.0, P=0.003), ASES (24.9, P=0.002), D ASH (-20.6, P=0.001), and Constant-Murley values (14.2, P=0.010). In addition, significant improvement was shown in postoperative flexion (17.3°, P=0.026) and external rotation (27.7°, P<0.001). In postoperative radiologic evaluations, the interposed tendons were intact at the last examination in 12 of the 13 patients. No complications related to donor sites were reported. An arthroscopic bridging graft for irreparable RCTs using a modified Mason-Allen stitch and a plantaris autograft resulted in improved short-term radiological and clinical outcomes. Graft integrity was maintained for up to 2 years in most patients. Level of evidence: IV.

Subacromial Balloon Spacer Versus Partial Rotator Cuff Repair in the Treatment of Massive Irreparable Rotator Cuff Tears: Facility Personnel Allocation and Procedural Cost Analysis.

Background The subacromial balloon is a novel technology that has shown promise in managing a select patient population with massive irreparable rotator cuff tears. The purpose of this study was to quantify the true facility cost difference between subacromial balloon placement (SBP) and partial rotator cuff repair (PCR). Methodology A prospective cohort of patients with massive irreparable rotator cuff tears randomized to SBP versus PCR between2015 and 2018 was retrospectively reviewed. Demographic variables, medical comorbidities, and range-of-motion (ROM) outcomes for all patients were recorded. True facility costs with respect to personnel were calculated using a time-driven activity based-costing (TDABC) algorithm and were classified into personnel costs and supply costs. Results Seven patients were treated with PCR compared to nine treated with SBP. No significant differences were observed with respect to demographic characteristics. Postoperative mean external rotation was 37° in SBP patients significantly higher than that of PCR patients at 8° (P= 0.023). Personnel time and cost differences while in the operating room (OR) were significantly less for the SBP ($605.58) compared to PCR ($1362.76) (P< 0.001). Implant costs were higher for SBP when compared to PCR, whereas disposable equipment costs were higher for PCR when compared to SBP. The total mean true facility cost was $7658.00 for SBP, significantly higher than that of PCR at $3429.00 (P< 0.001). Conclusions Despite the substantial reduction in personnel costs seen with SBP, the true facility cost of SBP was significantly higher than that of PCR. As this novel technology is used more ubiquitously and its price is negotiated down, the cost savings seen in personnel and OR time will become more significant. Future prospective cost analyses should follow up on the changes in implant costs and account for potential anesthesia cost savings.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study.

Reverse total shoulder arthroplasty (rTSA) has begun to challenge the place of anatomic total shoulder arthroplasty (aTSA) as a primary procedure for certain indications. One purported benefit of aTSA is improved postoperative range of motion (ROM) compared to rTSA especially in internal rotation; however, it is unclear whether aTSA can provide patients with significant preoperative stiffness superior ROM compared to rTSA. Our purpose was to compare clinical outcomes of aTSA and rTSA performed in stiff vs. non-stiff shoulders for rotator cuff intact (RCI) glenohumeral osteoarthritis (GHOA). A retrospective review of an international shoulder arthroplasty database identified 1608 aTSAs and 600 rTSAs performed for RCI GHOA with minimum 2-year follow-up. Defining preoperative stiffness as ≤ 0° of passive external rotation (ER), we matched: (1) stiff aTSAs (n=257) 1:3 to non-stiff aTSAs, (2) stiff rTSAs (n=87) 1:3 to non-stiff rTSAs, and (3) stiff rTSAs (n=87) 1:1 to stiff aTSAs. We compared ROM, outcome scores, and the rate of complications and revision surgery at latest follow-up. Despite stiff aTSAs having poorer preoperative ROM and functional outcome scores for all measures assessed (P<.001 for all), only poorer postoperative active abduction (113±27° vs. 128±35°; P<.001), active ER (39±18° vs. 50±20°; P<.001), and passive ER (45±17° vs. 56±18°; P<.001) persisted postoperatively compared to the non-stiff cohort. Similarly, stiff rTSAs had poorer preoperative ROM and functional outcome scores for all measures assessed compared to non-stiff rTSAs (P≤.044), but only poorer active abduction (108±24° vs. 128±29°, P<.001), active ER (28±17° vs. 42±17°, P<.001), and passive ER (36±15° vs. 48±17°, P<.001) persisted. When comparing stiff rTSAs to matched stiff aTSAs, no significant differences in preoperative ROM or functional outcome scores were found. However, stiff aTSAs had greater postoperative active internal rotation score (4.8±1.5 vs. 4.2±1.7, P=.022), active ER (40±19° vs. 28±17°, P<.001), and passive ER (46±18° vs. 36±15°, P=.001). Postoperative outcome scores were similar across all matched cohort comparisons despite motion differences. The rate of complications and need for revision surgery did not differ between any group comparisons. Patients with RCI GHOA who have preoperative rotational stiffness have poorer postoperative ROM compared with non-stiff patients following both aTSA and rTSA, but similar functional outcome scores. Notably, preoperative limitations in passive ER do not appear to be a limitation to utilizing aTSA. Indeed, patients with limited preoperative ER treated with aTSA had greater postoperative internal rotation and ER compared to those treated with rTSA.

Effect of primary diagnosis on return to sport after reverse total shoulder arthroplasty

BackgroundIncreasing evidence exists regarding the impact of primary diagnosis on clinical outcomes following reverse total shoulder arthroplasty (RTSA). Expanding indications coupled with emerging clinical evidence has resulted in increased use of RTSA for glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. The ability to return to sports after RTSA is a common concern for patients; however, most literature evaluating this does not stratify patients by diagnosis. The purpose of this investigation was to evaluate the effect of diagnosis on return to sports after RTSA. MethodsA single institution, retrospective study was performed on patients who underwent primary RTSA with a minimum 2-year follow-up. Patients answered a 7-question survey regarding sport participation within 3 years before surgery and the level to which they returned to their sports after surgery. Patient demographics, patient-reported outcome scores, and range of motion were accessed from the database. Descriptive statistics and univariate analysis were performed to assess differences between patients who did not return to sport or did so at lower level and those that returned at the same or higher level, as well as between patients with GHOA and those with rotator cuff disease. Binary logistic regression was performed to assess predictors of returning to sports. ResultsA total of 106 patients meeting inclusion criteria were identified with a mean age of 72 years (range, 55-88 years). Ninety-six patients (90.6%) returned to playing sports, of which 84 (87.5%) returned at the same or higher level. Patients with GHOA demonstrated a higher rate of return to sport compared to those with rotator cuff disease (95.6% vs. 81.6%; P = .033). Logistic regression controlling for sport intensity demonstrated that GHOA is a predictor of returning to sports (odds ratio = 6.3; P = .017). Patients who did not return to sports or did so at a lower level had higher preoperative pain (P = .007), lower postoperative SANE (Single Assessment Numerical Evaluation of the Shoulder) (P = .027), lower preoperative and postoperative ASES (American Shoulder and Elbow Surgeons) scores (P = .004 and P = .016, respectively), less preoperative and postoperative forward elevation (P = .037 and P = .019, respectively), lower postoperative external rotation (P = .004), and lower preoperative internal rotation (P = .027). ConclusionThe ability of patients to return to sports after RTSA is highly influenced by preoperative diagnosis. Patients with GHOA have higher rates of return to sport than previously recognized. These results are useful for establishing expectations with patients regarding their postoperative activity level.

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit

Background: Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed. Results: Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was −12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9). Conclusions: RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors associated with functional improvement after posteriorly augmented total shoulder arthroplasty.

Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study was to identify preoperative and postoperative factors that impact range of motion (ROM) and function after augmented TSA in patients with type B2 or B3 glenoid morphology. This was a retrospective review of all patients who underwent TSA with a step-type augmentation performed by a single surgeon between 2009 and 2018. Patients with Walch type B2 or B3 glenoids were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE) score, and visual analog scale pain score. Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and midglenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to ROM and functional outcome scores. Fifty patients (mean age, 68.1±8.0 years) with a mean follow-up period of 42.0 months (range, 24-106 months) were included. Glenoid morphology included type B2 glenoids in 41 patients and type B3 glenoids in 9. One patient had center-peg osteolysis, and 1 patient had glenoid component loosening. Average preoperative FE, ER, and IR were 110°, 21°, and S1, respectively. Average postoperative FE, ER, and IR were 155°, 42°, and L1, respectively. The mean postoperative visual analog scale score was 0.5±0.8, and the mean SANE score was 94.5±5.6. Type B3 glenoids were associated with better postoperative IR compared with type B2 glenoids (T10 vs. L1, P=.024), with no other differences in ROM between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative ROM. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with ROM in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r=-0.448, P=.006). Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative ROM and function showed no clinically important associations with preoperative or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented TSAs, except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

The Arthroscopic Bristow Procedure Is Superior to the Arthroscopic Latarjet Procedure in Return to Sports but Inferior in Graft Healing: A Comparative Study With 3.4-Year Follow-Up

To compare clinical and computed tomography outcomes between the arthroscopic Latarjet procedure and the arthroscopic Bristow procedure. Patients who underwent arthroscopic Latarjet or Bristow procedures with at least 2 years of follow-up were retrospectively reviewed. Thirty-eight shoulders were included in the Latarjet group, and 34 were included in the Bristow group. Recurrence of dislocation, clinical scores, rate of return to sports (RTS), and computed tomography assessment findings (position of transferred coracoid, graft healing, graft absorption, and glenohumeral degenerative osteoarthritis [OA]) were obtained at final follow-up. No recurrent dislocation occurred in either group, and no significant differences in clinical scores were found between the 2 procedures, with a mean follow-up period of 3.4 years. The operative time in the Bristow group was significantly shorter than that in the Latarjet group (P < .001). The transferred coracoid had healed in 94.7% of the patients in the Latarjet group and 85.3% in the Bristow group at final follow-up (P= .01). No significant difference in graft absorption or the degree of glenohumeral OA was detected between the 2 groups. However, moderate to severe OA only occurred in the Latarjet group at final follow-up (4 of 38 shoulders, 10.5%). The postoperative external rotation angle and level of RTS favored the Latarjet procedure (P= .030 and P= .034, respectively). Both the arthroscopic Latarjet and arthroscopic Bristow procedures led to good clinical scores with no new dislocation episodes. The Bristow group showed significantly less graft healing than the Latarjet group. However, the arthroscopic Bristow procedure took less operative time and showed a lower rate of early moderate to severe glenohumeral OA, better range of motion, and a higher rate of RTS. Level III, retrospective comparative therapeutic trial.