Postoperative Internal Rotation Research Articles

Increased glenoid baseplate retroversion improves internal rotation following reverse shoulder arthroplasty

BackgroundInternal rotation after reverse shoulder arthroplasty (RSA) is often unchanged or minimally improved. The primary purpose of this study was to investigate the effects of glenoid baseplate version on postoperative internal rotation. The secondary purpose to investigate the effects of baseplate retroversion on external rotation (ER) and patients reported outcomes (PROs). MethodsA retrospective review was performed on a prospectively maintained multicenter database of patients who underwent primary RSA using a 135° humeral prosthesis and lateralized glenoid with minimum 2-year clinical follow-up. Preoperative and postoperative radiographs were reviewed by two independent observers who assessed preoperative glenoid version and postoperative glenoid baseplate version. Patients were stratified by postoperative retroversion (<10°, 10-19° or >20°) and change in version from preoperative to postoperative (ΔRV). Primary outcomes were internal rotation with the arm at 90° (IR90) and internal rotation estimated to nearest spinal level (IRspine). Secondary outcomes were active external rotation in adduction (ER0), active external rotation with arm at 90° (ER90), forward flexion (FF), and PROs. Linear regression analyses and one-way analysis of variance (ANOVA) analyses were used for comparisons. Results274 patients with a mean of 71 years of age were included in the study. Patients with >10° of postoperative baseplate retroversion gained 20° of IR90 (p=0.005) without loss of ER90 (p<0.001) compared to patients with <10° of baseplate retroversion. More than 10° of postoperative baseplate retroversion was associated with significantly improved Constant-Murley scores (41.5, p=0.007) and SANE scores (45.4, p=0.047) compared to patients with less than <10° of baseplate retroversion. Patients with a ΔRV increase of > 10° had significantly improved IR90 (p=0.031) without loss of ER90 (p=0.019). There was no correlation between ΔRV and IRspine, ER0 or FF, or PROs. ConclusionWith a 135° and lateralized glenoid, postoperative baseplate retroversion of >10° was associated with significantly improved IR90, ER90, Constant-Murley and SANE scores at 2 years follow-up compared to <10° retroversion. Additionally an increased ΔRV from pre- to postoperative appears to improve IR90 without limiting ER0 or FF. While baseplate retroversion does not improve IRspine, overall function appears to be improved and therefore consideration may be given to accepting retroversion or intentionally retroverting the baseplate if fixation allows.

Does the subscapularis repair affect the clinical outcome after primary reverse shoulder arthroplasty?

BackgroundReverse shoulder arthroplasty is an established procedure for patients with rotator cuff tear arthropathy. However, the refixation of the subscapularis tendon remains a controversial and frequently discussed topic. This prospective randomized study was conducted to evaluate the clinical benefit of the subscapularis refixation after reverse shoulder arthroplasty. MethodsFifty patients (f: 36, m:14) were randomized and assigned to either the “repaired” (rep) or the “not repaired” (nrep) cohort. Intraoperatively, the subscapularis tendon was reattached in the rep-cohort with four tendon-to-tendon sutures, whereas no refixation was performed in the nrep-cohort. The Constant-Murley Score (CS) and the range of motion was evaluated preoperatively as well as 12 and 36 months postoperatively. The Subjective Shoulder Value (SSV) and the Lift-off test were performed 36 months postoperatively. The postoperative subscapularis integrity was assessed sonographically. ResultsTwelve months postoperatively the rep-cohort presented better results in the CS (rep: 71 vs. nrep: 66, p: 0.037). The normalized CS was 80% in the rep-cohort and 75% in the nrep-cohort (p: 0.114). At our last follow-up after 36 months we did not find significant differences between the rep-cohort and the nrep-cohort in the CS (rep: 76 vs. nrep: 75, p: 0.285) and normalized CS (rep: 91% vs. nrep: 91%, p: 0.388). Concerning internal rotation (in points) the rep-cohort achieved better results than the nrep-cohort (rep: 7.3 vs. nrep: 6.6, p: 0.040). Flexion (rep: 145° vs. nrep: 151°, p: 0.826), abduction (rep: 135° vs. nrep: 137° p: 0.816), external rotation (rep: 34° vs. nrep: 37°, p: 0.817) and the SSV (rep: 81% vs. nrep: 77%, p: 0.398) presented no significant differences between the cohorts. The ultrasound examination after 36 months displayed an intact tendon in 70%. ConclusionWhile the subscapularis refixation effects the postoperative internal rotation positively, there were no differences in mid-term follow-up concerning the overall results after rTSA. Further, the external rotation is not affected by the refixation of the subscapularis tendon.

Conjoint tendon lengthening improves internal rotation following reverse total shoulder arthroplasty: a cadaveric study

IntroductionReverse Shoulder Arthroplasty (RSA) is a common procedure for treating a variety of shoulder pathologies. However, many patients struggle with postoperative internal rotation deficits, which often hinder their activities of daily living. The conjoint tendon provides an anatomic barrier that can impede the postoperative internal rotation of the shoulder, and this study aims to evaluate the effect of a conjoint tendon lengthening on the glenohumeral range of motion following RSA. MethodsThis study used ten fresh-frozen cadaver specimens of the upper extremity. An RSA was implanted using a standard deltopectoral approach, and the range of motion was assessed post-implantation. Following this, the conjoint tendon was identified and lengthened using a tendon sheath z-plasty, and the range of motion was re-recorded. Statistical significance for the range of motion gains after conjoint tendon lengthening was determined with a significance level of p < 0.05. ResultsFollowing the lengthening of the conjoint tendon, there were statistically significant improvements in all ranges of motion (p < 0.05). Subjects demonstrated a notable gain in internal rotation to the back by 10.3 cm (p < 0.01), and all ranges of motion increased by at least 10°, except for forward flexion, which increased by 6° (p < 0.001). ConclusionsThis study suggests that lengthening the conjoint tendon improves postoperative range of motion of the glenohumeral joint after RSA, offering a potential solution to a considerable internal rotation deficits that are commonly encountered post-RSA. Subsequent clinical and biomechanical studies should assess the stability of the shoulder joint following conjoint tendon lengthening.

Preoperative diagnosis and rotator cuff status impact functional internal rotation following reverse shoulder arthroplasty

PurposeThis study aimed to evaluate whether functional internal rotation (fIR) following reverse shoulder arthroplasty (RSA) differs based on diagnosis of either: primary osteoarthritis (OA) with intact rotator cuff, massive irreparable rotator cuff tear (MICT) or cuff tear arthropathy (CTA). MethodsA retrospective review was performed on RSAs performed by a single surgeon with the same implant over a five year period. Minimum two year follow-up was available in 235 patients; 139 (59.1%) were females, and the mean patient age was 72±8 years. Additional clinical evaluation included the simple shoulder value (SSV) and Constant score. Postoperative internal rotation was categorized as type I: hand to the buttock or hip, type II: to the lower lumbar region, or type III smooth motion to at least the upper lumber region. Type I was considered “non-functional” internal rotation and type II or III were fIR. . ResultsPreoperatively, internal rotation was classified as type I in 60 (25.5%) patients, type II in 114 (48.5%), and type III in 62 (26%). Postoperatively internal rotation was classified as type I in 70 (30%) patients, type II in 86 (36%), and type III in 79 (34%). Compared to preoperative status, fIR improved significantly in OA patients (p<0.001), with 49 (52.6%) classified as type II or III postoperatively. In CTA patients, there was no significant change (p=0.352). In patients with MICTs, there was significant loss in fIR postoperatively (p=0.003), with 25 (30.8%) patients deteriorating to type I after having either type II or III preoperatively, and only five (6.1%) patients improving to either type II or III. ConclusionsPatients who undergo RSA for primary OA have a better chance of postoperative fIR improvement. A decrease in fIR is common after RSA for MICTs.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty

Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT). This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables. Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2±21.1 vs. 21.9±14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2±4.4 vs. 54.2±7.8 years, P<.001) and had more severe arthritis (1.8±0.9 vs. 1.2±0.5 Samilson-Prieto, P=.019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ±26° vs. 73°±30° change, P=.048), greater postoperative SSV (91±8% vs. 69±25%, P<.001), lower postoperative VAS pain scores (0.6±1.2 vs. 2.2±2.9, P=.020), and less postoperative internal rotation (IR; 4.6°±1.6° vs. 6.9°±1.8°, P=.004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (β=21.5, P=.021) and lower VAS scores (β=-1.4, P=.037), whereas SCR was predictive of greater IR ROM (β=3.0, P=.043). Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

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.

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.

Association of Severe Histological Degeneration of the Torn Supraspinatus Tendon and Retear After Arthroscopic Repair of Full-Thickness Rotator Cuff Tears Using the Suture Bridge Technique

Background: Previous studies have demonstrated several prognostic factors for retear after arthroscopic rotator cuff repair (ARCR). However, studies that histologically evaluate the quality of the torn rotator cuff (RC) tendon and its association with postoperative outcomes are limited. Purpose: To investigate factors associated with retear after ARCR using the suture bridge (SB) technique, including the degree of histological degeneration of the RC tendon edge. Study Design: Case-control study; Level of evidence, 3. Methods: The authors retrospectively evaluated 187 patients who underwent ARCR for full-thickness tears using the SB technique; intraoperative biopsy samples were taken to assess the degree of histological degeneration using the Bonar score. The cohort was divided into healed (n = 165) and retear (n = 22) groups according to magnetic resonance imaging results obtained ≥6 months postoperatively. The evaluation included preoperative patient data (age, sex, symptom duration, trauma history, history of heavy manual work, smoking habit, hypertension, diabetes mellitus, and hyperlipidemia) and radiological data (Hamada classification, Patte classification, Goutallier classification, and global fatty degeneration index [GFDI]). Additionally, intraoperative data (anteroposterior tear size, Lafosse classification for concomitant subscapularis tendon tear, and long head of biceps injury) and preoperative and postoperative clinical findings (active range of motion, University of California, Los Angeles [UCLA], score) were evaluated. Results: The retear rate was 11.8%. The retear group had a higher percentage of men (P = .031), higher Bonar score (P < .001), higher mean GFDI value (P = .002), higher rate of tear retraction degree (P = .010), and larger anteroposterior tear size (P = .020) than the healed group. The retear group had lower postoperative internal rotation (P = .031) and lower UCLA score (P < .001). Multivariate logistic regression analysis with a stepwise variable selection revealed anteroposterior tear size (odds ratio [OR], 2.4; 95% CI, 1.3-4.5; P = .004) and Bonar score (OR, 1.7; 95% CI, 1.3-2.4; P < .001) as independent predictors for a retear. Conclusion: The results indicate that end-stage severe tendon degeneration might affect retear. Therefore, further investigation on the progression mechanisms of tendon degeneration and development of methods to assess degenerative tissue might improve clinical outcomes after ARCR.

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.

High and low performers in internal rotation after reverse total shoulder arthroplasty: a biplane fluoroscopic study.

Internal rotation in adduction is often limited after reverse total shoulder arthroplasty (rTSA), but the origins of this functional deficit are unclear. Few studies have directly compared individuals who can and cannot perform internal rotation in adduction. Little data on underlying 3D humerothoracic, scapulothoracic, and glenohumeral joint relationships in these patients are available. Individuals >1-year postoperative to rTSA were imaged with biplane fluoroscopy in resting neutral and internal rotation in adduction poses. Subjects could either perform internal rotation in adduction with their hand at T12 or higher (high, N=7), or below the hip pocket (low, N=8). Demographics, the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and scapular notching grade were recorded. Joint orientation angles were derived from model-based markerless tracking of the scapula and humerus relative to the torso. The 3D implant models were aligned to preoperative computed tomography models to evaluate bone-implant impingement. The Simple Shoulder Test was highest in the high group (11±1 vs. 9±2, P=.019). Two subjects per group had scapular notching (grades 1 and 2), and 3 high group and 4 low group subjects had impingement below the glenoid. In the neutral pose, the scapula had 7° more upward rotation in the high group (P=.100), and the low group demonstrated 9° more posterior tilt (P=.017) and 14° more glenohumeral elevation (P=.047). In the internal rotation pose, axial rotation was >45° higher in the high group (P≤.008) and the low group again had 11° more glenohumeral elevation (P=.058). Large rotational differences within subject groups arose from a combination of differences in the resting neutral and maximum internal rotation in adduction poses, not only the terminal arm position. Individuals who were able to perform high internal rotation in adduction after rTSA demonstrated differences in joint orientation and anatomic biases versus patients with low internal rotation. The high rotation group had 7° more resting scapular upward rotation and used a 15°-30° change in scapular tilt to perform internal rotation in adduction versus patients in the low group. The combination of altered resting scapular posture and restricted scapulothoracic range of motion could prohibit glenohumeral rotation required to reach internal rotation in adduction. In addition, inter-patient variation in humeral torsion may contribute substantially to postoperative internal rotation differences. These data point toward modifiable implant design and placement factors, as well as foci for physical therapy to strengthen and mobilize the scapula and glenohumeral joint in response to rTSA surgery.

Predictors of Internal Rotation after Reverse Shoulder Arthroplasty.

Internal rotation (IR) remains unpredictable following reverse total shoulder arthroplasty (rTSA). This study aimed to determine if increasing IR limits range of motion in other planes, and to determine pre- and intra-operative factors associated with post-operative IR. A retrospective analysis of a single surgeon's primary rTSA with a single implant was undertaken, excluding patients with acute fracture or infection. A lesser tuberosity osteotomy (LTO) or subscapularis peel tenotomy was performed and repaired at the surgeon's discretion. One hundred sixty rTSA were included; 142 (88.8%) had documented IR both pre-operatively and at one-year follow-up. Variables were collected to determine their effect on IR at the 1-year follow-up point. A multivariate logistic regression was used to determine independent predictors of sufficient IR. Average age was 69.8 (range: 55-86) years and 55% (88/160) were female. Preoperatively, 20.4% of patients (29/142) had sufficient IR. This improved to 32.4% (46/142) one year following surgery, p<0.001). Factors associated with sufficient post-operative IR were female sex (p=0.05), decreasing body mass index (p=0.04), pre-operative IR (p=0.01), preoperative external rotation (ER) in adduction (p<0.001), radiographic evidence of LTO healing (p=0.02), increased one-year postoperative forward elevation (p<0.001), and increased one-year postoperative ER (p<0.001). Increased postoperative IR did not adversely affect forward elevation or ER. On multivariate analysis, higher preoperative IR and one-year postoperative forward elevation were independently associated with sufficient one-year postoperative IR. IR following rTSA continues to be modest and unpredictable. Independent predictors of sufficient post-operative internal rotation were higher preoperative IR and one-year postoperative forward elevation. In a Grammont-style rTSA system, humeral version, glenosphere lateralization, and glenosphere size do not appear to impact IR. Importantly, achieving sufficient IR does not come at the expense of other planes of motion.

Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.

Glenohumeral osteoarthritis (OA) is a common comorbidity in patients with rotator cuff tears. However, the efficacy of rotator cuff repair in patients with concomitant glenohumeral OA is still heavily debated. Thus, the purpose of this study was to compare the clinical and functional outcome measures following arthroscopic rotator cuff repairs in patients with concomitant glenohumeral OA vs. those without glenohumeral OA. A retrospective review of 206 consecutive patients who underwent arthroscopic supraspinatus repairs (both isolated and with accompanying infraspinatus and/or subscapularis involvement) between 2013 and 2018 with a minimum of 1-year follow-up was performed. Patients were separated into 2 groups based on the presence or absence of concomitant glenohumeral OA. The primary outcome was failure of repair, defined as the need for revision repair or a retear confirmed on postoperative magnetic resonance imaging. The secondary outcomes were patient-reported outcome measures including the visual analog scale pain score, Subjective Shoulder Value, and American Shoulder and Elbow Surgeons score; active range of motion (ROM); and strength testing. Within the OA cohort, a subgroup analysis was conducted to compare outcomes between patients with mild OA and patients with moderate to severe OA. There were 91 patients in the glenohumeral OA group and 115 patients in the control group. Significant differences in postoperative forward flexion (FF) ROM (153.55° ± 21.07° vs. 160.14° ± 17.26°, P = .001) and external rotation (ER) ROM (46.91° ± 11.95° vs. 52.25° ± 11.60°, P = .001) were observed between the glenohumeral OA and control groups. There were no significant differences between groups in revision repairs, retears, postoperative internal rotation ROM, all preoperative ROMs, all patient-reported outcome measures, and all strength parameters (all P > .05). For the subgroup analysis, there were 70 patients in the mild OA group and 21 patients in the moderate to severe OA group. We found a significant difference in postoperative FF strength (88.4% vs. 61.9% with 5 of 5 strength, P = .010) and ER strength (89.9% vs. 71.4% with 5 of 5 strength, P = .046) between the mild OA group and moderate to severe OA group. There were no significant differences between the groups in all other outcome measures. Rotator cuff repair remains an excellent treatment option in patients with concomitant glenohumeral OA. The data in this study demonstrate that rotator cuff repairs in patients with concomitant glenohumeral OA have similar clinical and functional outcomes to repairs in patients without OA with the exception of slightly decreased postoperative FF and ER ROM. Patients with moderate to severe OA may have slightly decreased FF and ER strength outcomes compared with patients with mild OA.

Arthroscopic Repair of Isolated Subscapularis Tears Show Clinical and Structural Outcome Better for Small Tears Than Larger Tears

PurposeTo retrospectively investigate the mid-term outcomes after arthroscopic repair of isolated subscapularis tears with a relatively large number of patients and to compare them by tear size.MethodsMedical records were reviewed for patients who underwent arthroscopic rotator cuff repair between 2010 and 2017 at our institute. The inclusion criterion was isolated subscapularis tears that underwent arthroscopic rotator cuff repair. The exclusion criteria were (1) previous rotator cuff surgery, (2) lack of imaging studies or clinical evaluation data, (3) neuromuscular diseases, and (4) <2-year follow-up. Range of motion, American Shoulder and Elbow Society score, and bear-hug or belly-press test were assessed pre- and postoperatively. Repair integrity was evaluated with magnetic resonance imaging at postoperative1 year. The clinical and imaging study outcomes were compared between smaller (Lafosse types 1-3) and larger (types 4 and 5) tears.ResultsThe subjects included 38 males and 8 females with a mean age of 59 years (range, 25-77 years). The mean follow-up was 36 months (range, 24-96 months). There were 13 type 1, 10 type 2, 12 type 3, 6 type 4, and 5 type 5 shoulders. Postoperative American Shoulder and Elbow Society scores were significantly better in smaller tears than larger tears: 93 ± 8 and 75 ± 14, respectively (P = .003). Smaller tears showed better postoperative internal rotation than larger tears (P = .004). Significant decrease of positive bear-hug or belly-press test was observed in smaller tears (preoperative, 25; postoperative, 11; P < .001), but there was no significant improvement in larger tears (preoperative, 11; postoperative, 9). The retear rate was significantly greater in larger tears (64%) than smaller tears (6%, P < .001).ConclusionsThe clinical and structural outcomes after arthroscopic repair of isolated subscapularis tears were better in smaller tears than larger tears with a mid-term follow-up. Larger tears showed high retear rates with poorer improvement in active range of internal rotation and subscapularis strength.Level of EvidenceLevel III, retrospective, comparative study.

Severe Obesity Is Not Associated With Worse Functional Outcomes Following Arthroscopic Rotator Cuff Repair

The purpose of this study is to investigate the outcomes of arthroscopic rotator cuff repair in a severely obese population (body mass index [BMI] > 0 kg/m2) compared to a healthy weight population (BMI 18.5-24.9 kg/m2). This study is a retrospective review of prospectively collected data examining the outcomes of arthroscopic rotator cuff repair in both severely obese patients and healthy weight patients. Primary outcome measures analyzed include the American Shoulder and Elbow Surgeons (ASES) Score, the Single Assessment Numeric Evaluation (SANE), pain Visual Analog Scale (VAS), range of motion, and complications. A total of 89 patients met inclusion/exclusion criteria: 52 healthy weight patients (BMI 18.5-24.9 kg/m2) and 37 severely obese patients (BMI >40 kg/m2). Patient-reported pain and functional outcomes had significantly improved after surgery in both groups with regard to the visual analog score (VAS) scores, Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons Shoulder (ASES) scores (P < .0001). When directly comparing the outcomes in the healthy weight group to the severely obese group, the latter had significantly inferior outcomes in VAS scores (P= .0048), SANE scores (P= .0118), ASES scores (P= .0031), and postoperative internal rotation (P=.0132). At large, these outcomes did not have clinically significant differences. The severely obese group also had higher total numbers of comorbid conditions and longer operative times (P=.0041). Severely obese patients and their associated comorbid conditions pose unique challenges in rotator cuff tear management, but they still achieve overall excellent outcomes after repair and noninferior clinical differences when compared to healthy weight patients. Level III, retrospective comparative study.

Anterior acetabular coverage and femoral head-neck measurements predict postoperative anterior impingement: A simulation study.

The aim of this simulation study was to evaluate the relationship of elements of anterior acetabular coverage and femoral head-neck shape with the occurrence of postoperative anterior impingement after curved periacetabular osteotomy (PAO). Sixty-two patients with symptomatic developmental dysplasia of the hip who had undergone curved PAO were selected. The likelihood of developing postoperative anterior impingement was explored through simulations of the range of motion by collision detection of the pelvis and femur. Postoperative anterior impingement was defined as impingement that occurred during postoperative bone flexion <105° or postoperative internal rotation <20° at 90° flexion. The three-dimensional center-edge (CE) angles, acetabular and femoral versions, radiographic alpha angles of the femoral head, combination angles of anterior CE and alpha angles, and combined anteversions of acetabular and femoral versions were compared between patients with postoperative anterior impingement and nonimpingement. A receiver operator characteristic (ROC) analysis was conducted to determine thresholds of the examined radiographic parameters and calculate their accuracy for predicting postoperative anterior impingement. A multivariate analysis was performed to test whether combined anteversion, anterior CE angle, and combination angle are associated with excellent modified Harris Hip Scores (mHHSs).ROC analysis demonstrated a combination angle ≥108° was predictive of the occurrence of postoperative anterior impingement after curved PAO, which can lead to impaired clinical outcomes. Conversely, a combination angle <108° was significantly associated with mHHS ≥ 90 points. To avoid postoperative anterior impingement, osteochondroplasty of the femoral head or anterior CE angle control should be performed for patients with preoperative combination angles ≥90°.

Mid-term clinical and radiological outcomes of arthroscopic repair of isolated and combined subscapularis tears: A single-center experience.

The aim of this study was to evaluate the mid-term clinical and radiological results of patients who underwent arthroscopic subscapularis (SSC) tendon repair and to address the possible effect of repair technique(single or double row), tear pattern, and concomitant procedures among supraspinatus tears and long head of biceps tendon (LHBT) pathologies on outcomes and failure parameters. 45 patients (24 female; mean age = 55.9 years, age range = 37 - 78) who underwent arthroscopic repair of an SSC tear between January 2009 and December 2016 were retrospectively identified and included inthe study. Pre- and postoperative internal rotation strength and shoulder joint range of motion angles were measured. Clinical outcomes were assessed by Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant-Murley, Rotator cuff-quality of life (RC-QoL), and University of California Los Angles (UCLA) scores preoperatively and at the final follow-up. The mean follow-up was 45.2 (range = 36-104) months. 14 patients had isolated SSC tears. The mean preoperative VAS, ASES, Constant-Murley, RC-QoL, and UCLA scores for all patients were respectively 8.6, 21.2, 24, 28.9, and 12. Significant improvement was observed in each clinical outcome at the final follow-up: 0.96, 88.4, 86.4, 90.2, and 32.2, respectively. Improvement in outcome scores was more prominent in patients with Lafosse grade I and II SSC tendon tears repaired by singlerow technique and in patients with concomitant supraspinatus tendon repairs. The mean preoperativeinternal rotation strength according to theOxford scalewas 3.4 (±0.6) / 5 and raised to 4.7 (±0.4) / 5 at the final follow-up (P <.001).Although concomitant biceps interventions significantly improved the outcome scores; this improvement was not clinically significant. Failure was only seen in 6 patients with high-grade (Lafosse III or IV) tears. Significant improvement in clinical outcomes and lower failure ratios were more prominent in patients with Lafosse grade I or II tears than grade III or IV. Concomitant biceps interventions made a positivecontribution to the clinical outcome. Early diagnosis and repair seem to be advantageous before low-grade SSC tendon tears turn into high-grade tears. Level IV, Therapeutic Study.

Does Humeral Component Version Affect Range of Motion and Clinical Outcomes in Reverse Total Shoulder Arthroplasty? A Systematic Review.

Background: Prosthesis selection, design, and placement in reverse total shoulder arthroplasty (RTSA) affect post-operative results. The aim of this systematic review was to evaluate the influence of the humeral stem version and prosthesis design (inlay vs. onlay) on shoulder function following RTSA. Methods: A systematic review of the literature on post-operative range of motion (ROM) and functional scores following RTSA with specifically known humeral stem implantations was performed using MEDLINE, Pubmed, and Embase databases, and the Cochrane Library. Functional scores included were Constant scores (CSs) and/or American Shoulder and Elbow Surgeons (ASES) scores. The patients were organised into three separate groups based on the implanted version of their humeral stem: (1) less than 20° of retroversion, (2) 20° of retroversion, and (3) greater than 20° of retroversion. Results: Data from 14 studies and a total of 1221 shoulders were eligible for analysis. Patients with a humeral stem implanted at 20° of retroversion had similar post-operative mean ASES (75.8 points) and absolute CS (68.1 points) compared to the group with humeral stems implanted at less than 20° of retroversion (76 points and 62.5 points; p = 0.956 and p = 0.153) and those implanted at more than 20° of retroversion (73.3 points; p = 0.682). Subjects with humeral stem retroversion at greater than 20° tended towards greater active forward elevation and external rotation compared with the group at 20° of retroversion (p = 0.462) and those with less than 20° of retroversion (p = 0.192). Patients with an onlay-type RTSA showed statistically significantly higher mean post-operative internal rotation compared to patients with inlay-type RTSA designs (p = 0.048). Other functional scores and forward elevation results favoured the onlay-types, but greater external rotation was seen in inlay-type RTSA designs (p = 0.382). Conclusions: Humeral stem implantation in RTSA at 20° of retroversion and greater appears to be associated with higher post-operative outcome scores and a greater range of motion when compared with a retroversion of less than 20°. Within these studies, onlay-type RTSA designs were associated with greater forward elevation but less external rotation when compared to inlay-type designs. However, none of the differences in outcome scores and range of motion between the humeral version groups were statistically significant.

Superior capsular reconstruction for irreparable rotator cuff tears: Autografts versus allografts

AimsSuperior capsular reconstruction (SCR) is a treatment option for patients with massive irreparable rotator cuff tears. Different types of grafts from various donor sites have been described. There are no clinical studies comparing the different grafts available. The aim of this study is to compare the early clinical outcomes of patients who have undergone arthroscopic SCR with different types of grafts (allograft vs. autograft). Material and methodsThis study is a retrospective analysis of data collected prospectively, from patients who underwent arthroscopic SCR with either a long head of biceps autograft (LHB) (n=40) or an acellular dermal allograft (n=40), between March 2015 and April 2018. The pre- and postoperative clinical data were compared between the 2 groups, as well as the incidence and type of complications. ResultsAll patients were monitored with a minimum follow-up of one year. Three patients (7.5%) in the autograft group, and 14 (35%) in the allograft group (p=0.005) had a complication, of which 2 (5%) and 5 (12.5%) respectively, required revision surgery (p=0.432). Linear regression ruled out any significant difference between the 2 groups, with respect to clinical scores. However, patients with a history of prior rotator cuff surgery had poorer results with regard to active elevation (β, −29.3; p=0.020), internal rotation (β, −3.4; p=0.003) and Subjective Shoulder Value (SSV) (β, −17.2; p=0.023). Older patients, as well as men, are associated with poorer postoperative internal rotation (β, −0.1; p=0.003 and β, −1.9; p=0.039 respectively), and type D lesions are associated with poorer external rotation and postoperative SSV (β, −11.3; p=0.012 and β, −12.4; p=0.048 respectively), compared to type C lesions. Postoperative graft integrity was improved in the autograft group compared to the allograft group. (Grade 1: 65.8% vs. 2.9%; Grade 5: 5.3% vs. 28.6%; p<0.001). ConclusionsIn both groups, clinical scores improved after SCR in patients with irreparable rotator cuff tears. Fewer complications and revisions were observed with the autograft compared to the allograft. If the LHB was still in place during surgery, its use appears valid, given the reasonable cost and low rate of complications associated with it. If absent, an allograft is also an option, considering the potential clinical improvement. Level of evidenceIII; Case-control study.

The effect of glenoid version on internal and external rotation in reverse total shoulder arthroplasty

BackgroundThere is currently limited understanding of the contribution of glenoid version to postoperative internal (IR) and external rotation (ER) after reverse total shoulder arthroplasty (RTSA). The purpose of this study was to determine the impact of glenoid version on postoperative rotation after RTSA. MethodsForty-five 3-dimensional (3D) computer models of human scapulae were created from de-identified computed tomography (CT) scans. The scapulae were divided into 3 separate groups based on glenoid version: normal (10° to -10°), moderate (-10 to -25°), and severe (< -25°). The scapulae then underwent virtual implantation with a Grammont-style RTSA prosthesis at either 0°, -20°, or -30° of retroversion based on the severity of the native glenoid version (normal, moderate, severe). Internal, external, and total rotation (TR) were determined for each construct at both 30° and 60° of humeral abduction. ResultsGlenoids with a narrow width (< 25 mm) were noted to have minimal bony impingement on rotational testing and were excluded. In the remaining scapulae (n = 34), the achievable TR and IR for the humeral component decreased as glenoid retroversion increased. Changes in rotation for all categories were in general more pronounced at 60° of humeral abduction. Overall, ER generally increased as glenoid retroversion increased, with the largest increase occurring when going from 0° to -20° of retroversion, and minimal increase from -20° to -30° of retroversion regardless of humeral abduction. ConclusionPlacement of the glenoid component in increasing retroversion during RTSA results in a loss of IR and a corresponding increase in ER. Level of EvidenceBasic Science Study

L-Shaped Arthroscopic Posterior Capsular Release in Frozen Shoulder

Background: The inadequate arthroscopic release of the tight posterior capsule in frozen shoulder may result in limited postoperative shoulder internal rotation. Indication: The purpose of this article is to describe an L-shaped arthroscopic posterior capsular release to overcome the limited internal rotation that may be encountered following the standard longitudinal technique. Operative intervention is indicated in patients with refractory shoulder stiffness with limitation of internal rotation of grade 0, +2, +4 (according to the Constant-Murley Score), after failure of conservative measures for 3 to 6 months. The technique is contraindicated if less than 3 months of physical therapy, shoulder stiffness due to osseous deformity, infection, or cuff tear arthropathy. Technique: After performing a standard anterior capsular release, the scope is shifted to the anterior portal to perform posterior capsular release by introducing the radiofrequency ablation device through the posterior portal. Posterior release begins from the glenoid level down to the 6 o’clock position until the back fibers of the infraspinatus muscle appear. Then the hook-tip part of the radiofrequency ablation device is used to perform a transverse release in the posterior capsule, starting from the beginning of the longitudinal limb. The transverse limb is performed in a stepwise manner going step-by-step laterally but ending before reaching the rotator cuff to avoid any damage of the cuff. After that, the shoulder was manipulated according to Codman technique. Results: A comparative study was performed on 43 patients with primary frozen shoulder to compare the standard longitudinal (22 patients) and L-shaped (21 patients) posterior capsular release. At the final follow-up, there was a statistically significant improvement in the internal rotation range of motion in the L-shaped group ( P &lt; .001). There was no loss of function over time. Moreover, there were no infections, instability, or axillary nerve injury in either group. Discussion/Conclusion: Restriction of internal rotation in frozen shoulder has been attributed to posterior capsular tightness. The L-shaped arthroscopic posterior capsular release in patients with primary frozen shoulder significantly improves the postoperative internal rotation range of motion.