SANE Score Research Articles

Impact Evaluation and Cost–Benefit Analysis of Remote Orthopedic Consultation Methods in a Low-Resource Health-Care Setting

Background: Geographic barriers, inadequate infrastructure, and large-scale logistics severely limit telemedicine and e-health systems' ability to make orthopedic care accessible to masses in rural centers. With <1% of the registered hospitals in our country connected through telemedicine, novel alternatives are necessary for effective remote consultation in low-resource health-care settings. Materials and Methods: A retrospective cohort analysis to compare the impact of “e-mail and telephone-” and “WhatsApp-” assisted remote orthopedic consultations (ROCs) on surgical decision-making and outcome of complex orthopedic conditions treated at a remote location hospital in Central India was conducted by assessing the response time, clarity, peer review accessibility, cost-effectiveness and functional outcome parameters (Visual Analog Score [VAS] and Single Assessment Numerical Evaluation [SANE]), complication rates, and duration of hospital stay. Unpaired t-test was used for statistical analysis. Results: Forty-eight patients were included in the study. Remote consultation was carried out through “e-mail and telephone” for 17 patients and through “WhatsApp” for 31 patients. “WhatsApp-” assisted remote consultation enabled quicker response (P < 0.0001), ensured nonambiguity (P < 0.0001), was cost-effective, and facilitated more peer review (P < 0.0001). Mean VAS and SANE scores reflected better outcome in the “WhatsApp-” assisted remote consultation (P < 0.0001), but hospital stay and complication rates were higher in this group. Conclusions: “WhatsApp-” assisted ROC had a higher impact and was cost-effective in management of complex orthopedic conditions in the low-resource setting.

Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency

We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes. Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected. The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P= .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n= 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P= .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n= 12), significant improvement was seen in postoperative FE (108 vs 158°; P= .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n= 3), there were no distinguishing characteristics present. Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes. IV, retrospective cohort.

Understanding the variables that are associated with failure to achieve an acceptable symptom state after reverse shoulder arthroplasty

BackgroundThe patient acceptable symptom state (PASS) was developed to improve the subjective interpretation of patient reported outcomes (PROs) and the minimum score necessary for the patient to “feel good.” The purpose of this study was to compare range of motion (ROM), final PROs, and individual responses on PROs between patients achieving or failing to meet a PASS after reverse shoulder arthroplasty (RSA). MethodsA retrospective review of multi-center prospectively maintained database of RSAs between 2015 and 2018 was conducted. Primary RSAs with minimum 2-year follow-up were included. Patients were stratified into 2 groups by whether they achieved or failed to meet PASS scores at a minimum of 2 years of 76 for the ASES score or 75.5 for the SANE score. The primary goals of the study were to compare outcomes, range of motion (ROM) and individual ASES and WOOS survey responses for patients above and below the PASS score. Results87 patients were included. Using the ASES cutoff for PASS, 33% failed to meet a PASS while 45% failed to meet a PASS defined by the SANE. The most notable difference between patients above and below ASES PASS was a significant difference in VAS pain scores (3.1 vs. 0.3; P < .001). Overall, ROM was similar between patients above and below the ASES PASS, with slight, but statistically improved rotational motion in those achieving an ASES PASS (ER(90) 14 degrees improved, P = .005, IR(90) 10 degrees improved, P = .011). Similarly, patients failing to meet the SANE PASS had twice as high VAS pain scores (1.9 vs. 0.8; P = .017). Patients failing to meet the ASES PASS had almost universally statistically higher rates of reporting “very difficult” or “unable to do” for pain, ADL and work/sports questions on the ASES and globally more symptoms on every domain of questions for the WOOS. Similarly, for the PASS defined by SANE, patients reported higher levels of pain and dysfunction on nearly every question and domain of the ASES and WOOS. ConclusionsAt least one quarter of patients do not achieve a PASS after RSA. Pain appears to be the primary driver for this finding, while ROM is very similar between patients achieving or failing to meet a PASS regardless of PRO used to define the PASS. Patients who fail to achieve PASS after RSA report doing poorly in all domains of their outcome. Level of evidenceLevel III; Retrospective Comparative Study

High rate of anatomic reduction and healing of tuberosities with a fracture specific cemented stem in reverse total shoulder arthroplasty for proximal humerus fracture

ABSTRACT Hypothesis Using a modern stem designed for use in reverse total shoulder arthroplasty for fracture will enable accurate and effective tuberosity reduction and healing Methods Twenty-five (25) shoulders were included, with a minimum of 1 year of follow-up. Radiographs and clinical outcome scores were reviewed. Results The average age of patients was 72. The average postoperative ASES score was 83 ± 8. Average SANE scores were 82 ± 15. Modified Neer scores were able to be calculated on 23 patients, with 21 patients (91%) having excellent (14) or satisfactory (7) outcomes. Tuberosity reduction was “anatomic” in all shoulders. There was one shoulder (4%) that had tuberosities that displaced into a “nonanatomic” position. Mild displacement of the tuberosities, and tuberosity resorption were common. No stems or glenoid components loosened or were considered “at risk.” Discussion With modern stem design emphasizing tuberosity reduction and fixation, and modern repair constructs, tuberosity reduction and healing are reliable. Clinical outcomes are excellent, with 91% having excellent or satisfactory clinical outcomes. Level of Evidence Level IV; Treatment Study

Outcomes of rotator cuff repair with concurrent microfracture of focal glenohumeral osteoarthritis

The benefit of rotator cuff repair (RCR) in patients with concurrent osteoarthritic changes remains unclear. RCR has the theoretical potential to increase the compressive force across the glenohumeral joint, further exacerbating osteoarthritis pain. The purpose of this study is to investigate pain relief and patient-reported outcomes of patients undergoing simultaneous RCR and microfracture of focal glenohumeral osteoarthritis. Thirty-four patients undergoing simultaneous RCR and microfracture were retrospectively reviewed at a minimum 1-year follow-up. Patient demographics, preoperative range of motion, functional outcomes (visual analog scale [VAS], Single Assessment Numeric Evaluation [SANE], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], and Simple Shoulder Test [SST]), and operative metrics were recorded. The patients were then contacted to obtain postoperative functional outcome scores (VAS, SANE, ASES, and SST). Twenty-seven patients (11 male/16 female [79%]) were evaluated at a mean follow-up of 25.8 months (range, 12-46). The average age at surgery was 64.9 years (range, 56-78). Chronic tears were more common than acute tears (57.7% vs. 42.3%). The majority of patients had a full rotator cuff tear (89%) involving a mean 1.7 ± 0.8 tendons (range, 1-3). Eighty-eight percent of the humeral lesions were Outerbridge 4 compared with 84% on the glenoid. The mean estimated involvement between the 2 groups with 38.4% ± 18.4% of the humeral head involved and 34.6% ± 18.4% of the glenoid involved. PRO scores improved postoperatively with a reduction in mean VAS (6.6-2.0, P < .01), SANE (33.8-79.8, P < .01), ASES (38.0-80.9, P < .01), and SST (3.07-9.70, P < .01) scores. Cumulatively, only 52% (14/27) of the patients improved, however, by the MCID for all collected PROs. Our results demonstrate modest improvements in postoperative pain and functional scores at a minimum of 1-year follow-up in a cohort of patients who have undergone RCR and glenohumeral microfracture. In cases of small focal lesions of full-thickness cartilage loss, RCR with microfracture is a reasonable treatment option; however, patients should be counseled on expectations accordingly.

Is distal peripheral neuropathy common after shoulder arthroplasty?

BackgroundNeurologic injury after shoulder arthroplasty has been reported in previous outcome studies. However, the incidence and development of distal peripheral neuropathy (DPN) after shoulder arthroplasty requiring surgical intervention has not been previously described. HypothesisThe authors report on the incidence of DPN requiring surgical intervention following shoulder arthroplasty. MethodsA retrospective review was conducted of a prospectively collected shoulder arthroplasty registry at a single institution from a single surgeon from April 2006 to April 2017. Patients were included in the series if they had primary surgical intervention for ipsilateral or contralateral peripheral neuropathy following primary shoulder arthroplasty. Patients were excluded if they had known peripheral neuropathy or cervical radiculopathy prior to surgery. DPN was defined for the study as symptoms or diagnostic testing consistent with cubital tunnel or carpal tunnel syndrome. Demographics, patient reported outcome measures, and preoperative and postoperative shoulder range of motion were collected and analyzed with paired t-tests and multivariate regression models. ResultsOne thousand three hundred eighty-seven total shoulder arthroplasties were performed in this period. During the study period, 16 patients (1.2%) underwent surgery for ipsilateral DPN while 6 patients (0.4%) underwent surgery for contralateral DPN. ASES scores, SANE scores, and shoulder flexion improved significantly from pre- to postoperatively for both groups. There was no significant difference in postoperative scores between groups. Finally, the multivariate linear analysis did not yield any statistically significant regression equations for ASES, SANE VAS, AFE, and AER. ConclusionShoulder arthroplasty resulted in increased ipsilateral distal peripheral neuropathy. Emergence of DPN symptoms following arthroplasty is multifactorial and may be related to a form of the double crush syndrome. Level of evidenceLevel IV; Case series

The histopathology of the humeral head in glenohumeral osteoarthritis

ObjectiveThe histopathologic wear patterns in glenohumeral osteoarthritis (GOA) have not been described. The aims of the study were to a) describe the histopathology of humeral head wear patterns in patients with end-stage GOA and b) identify clinical and radiographic parameters that correlate with observed histopathological wear patterns. MethodsEighteen humeral heads from patients undergoing anatomic total shoulder arthroplasty for end-stage osteoarthritis were divided radially into eight wedge-shaped zones. Each zone was subdivided into central and peripheral regions. Histologic analysis included measurements of cartilage and subchondral bone plate thickness, subchondral bone area, and cartilage structure was scored using the Osteoarthritis Research Society (OARSI) and modified Mankin systems. Clinical variables including patient history, physical exam, functional evaluation, and radiographic assessments were evaluated for correlations with humeral head characteristics. ResultsOverall, humeral heads demonstrated a pattern of central and inferior cartilage damage, loss, and subchondral bone changes. However, within the group, composite maps of individual patient wear patterns demonstrated a sub-group of patients with a more focal inferior cartilage lesion. Overall, these more focal inferior lesions were associated with greater pre-operative range of motion (in both upper extremities), higher pre-operative SANE and ASES scores, female sex, non-dominant extremity, concentric wear patterns, and smaller inferior osteophytes. ConclusionHumeral head cartilage wear patterns in GOA include central and inferior cartilage damage and loss. A histopathological distinction was identified between patients with more focal versus diffuse wear, which may manifest clinically with preservation of function and range of motion, and with less profound radiographical changes.

Anatomic shoulder arthroplasty in workers’ compensation patients: predictors of success and return to work

BackgroundIn patients with shoulder arthritis, workers’ compensation (WC) status presents unique challenges to the clinician because of the socioeconomic and psychosocial aspects attendant to patients covered on this type of insurance. Patients, surgeons, and these insurance programs would be informed by a better understanding of the factors that may impact the results of a shoulder arthroplasty as treatment for glenohumeral arthritis in this population. The objectives of this study were to determine: (1) the extent to which patient-reported outcomes are impacted by WC status in comparison to patients covered by other types of insurance, (2) which factors are predictive of a successful outcome of shoulder arthroplasty as defined by improvement exceeding the minimal clinically important difference (MCID), (3) the ability of WC patients to return to their presurgical occupation after arthroplasty. MethodsThis was a retrospective study of a longitudinally maintained institutional database of 677 patients who underwent primary anatomic shoulder arthroplasty with a minimum 2-year follow-up, 39 of whom had WC insurance. These patients were compared to a matched cohort of 78 patients without WC insurance. Primary outcome measures included SST scores, SANE scores, and need for revision surgery. Univariate and multivariate analyses were performed to determine preoperative characteristics associated with success as defined by improvement greater than the MCID of the SST. ResultsSuccess, defined as improvement beyond MCID, occurred in a significantly lower proportion of WC patients compared to non-WC patients (64% vs. 94%, P< .001). Older age (P= .010) and a higher preoperative SF-36 role physical domain score (a measure of the patient's perceived limitations in routine activities;P= .007) were associated with improvement beyond the MCID on univariate analysis. Higher preoperative SF-36 role physical domain scores had the greatest correlation with a successful outcome (OR 1.19, 95% 0.99-1.43, P= .07). A significantly lower percentage of patients with physically-demanding jobs returned to previous occupation compared to patients with non-physically-demanding jobs (13% vs. 73%, P= .001). ConclusionsThe challenges in treating patients covered by WC are underscored by the high percentage of these patients that do not improve beyond the MCID and the high percentage of patients with physically-demanding jobs that are unable to return to their presurgical occupation. Those patients who report less disability with routine daily activities (ie, higher SF-36 role physical domain scores) may fare better with anatomic shoulder arthroplasty. Patients with physically-demanding jobs should be counseled that return to their previous occupation is unlikely. Level of EvidenceLevel III; Retrospective Cohort Comparative Study

American Academy of Sports Physical Therapy Platform Presentation Abstracts SPL1–SPL82

American Academy of Sports Physical Therapy Platform Presentation Abstracts SPL1–SPL82

Establishing thresholds for achievement of clinically significant satisfaction at two years following shoulder arthroplasty: the patient acceptable symptomatic state

BackgroundThe patient acceptable symptomatic state (PASS) represents clinical improvement following surgery that patients deem as satisfactory; however, thresholds for achieving this clinical benchmark have not yet been established beyond 1 year following primary and reverse shoulder arthroplasty. MethodsA prospectively maintained registry was retrospectively queried for patients undergoing either a primary TSA or RTSA at a single institution between November, 2015 and October, 2017. All patients completed the ASES, SANE, and Constant patient-reported outcome (PRO) scores at the 2-year time point. PASS threshold scores were calculated using anchor-based methodology with subsequent calculation of achievement rates. Multivariate logistic regression was used to identify demographic and clinical variables associated with the likelihood of PASS achievement. ResultsA total of 93 TSA (mean age 61.4 ± 8.5 years, 32.3% female) and 111 RTSA (mean age 70.0 ± 8.1 years, 51.4% female) patients met final inclusion criteria. One-hundred sixty-five patients (80.8%) responded to the binary anchor question as “satisfied” regarding their surgical outcome. The PASS cutoffs for ASES, SANE, and Constant were 81.7, 85.7, and 24.0, respectively (AUC > 80%), with PASS achievement rates ranging from 50.7% to 59.9% for the entire study population and 66.7% to 83.3% for a risk-stratified subgroup. Patients undergoing TSA had a significantly higher PASS achievement rate relative to RTSA (P = .010) for ASES. Independent risk factors for decreased PASS achievement included lower preoperative PRO score, prior shoulder surgery, sedentary lifestyle, smoking, workers’ compensation status, and diabetes mellitus (DM). ConclusionThe majority of patients reach the PASS benchmark by 2 years after shoulder arthroplasty, with an optimal subgroup of risk-stratified patients achieving PASS at a rate greater than 80% for ASES. Patients undergoing TSA have a higher likelihood of reaching the PASS than patients undergoing RTSA, independent of other variables. Lower baseline outcome scores, prior shoulder surgery, smoking, and sedentary lifestyle are associated with lower PASS rates after TSA. Worker's compensation status and comorbid DM are predictive of reduced PASS rates after RTSA. Primary diagnosis and glenoid morphology did not have a significant impact on the rate of achieving the PASS. This information is valuable for patient selection and counseling prior to shoulder arthroplasty. Level of EvidenceLevel III; Prognostic Study; Retrospective Case Series.

Outcomes of Arthroscopic Loose Body Management in Patella Instability: Medial Patellofemoral Ligament Neglect or Repair Versus Reconstruction

Objectives:Patellar instability is common in adolescents during their growth. Management of the actual patellar instability at the time of arthroscopic treatment for concomitant intra-articular loose body has been debated since many surgeons will manage first-time dislocations without surgery. To demonstrate that medial patellofemoral joint reconstruction, rather than neglect or repair of the ligament, should be performed at the time of arthroscopic loose body removal for first-time patellar instability events in children.Methods:Retrospective study design was performed on all patients who sustained a patellar instability event that resulted in an intra-articular loose body between 2011 and 2017 at our institution. Data was collected using ICD-9/10 and/or CPT codes. Patients included in the analysis were required to have a minimum of 24 month follow-up documented. We then performed chart review and radiographic review (XR and MRI). Variables collected included: demographics, weight, BMI, pain score, SANE score, Kujala score, subsequent recurrent instability, need for second surgery, growth plate status, trochlear dysplasia, TT-TG, Insall-Salvati ratio, and Blackburne-Peel ratio. Data analysis pooled the “neglect” and “repair” groups together and compared it to the “reconstruction” group. Continuous variables were examined for normal distribution and homogeneity and analyzed with ANOVA or Mann Whitney. Chi square was utilized for categorical variables.Results:64 patients (34 males, 30 females) with a mean age at surgery of 14 years (range 9 to 18) met criteria. These participants had a reported mean weight (kg) and BMI of 67.6 kg and 23.9, respectively. In our two-cohort analysis, the reconstruction cohort demonstrated significantly less subsequent instability, with the rate of recurrence being 58.7% in the neglect/repair compared to 16.7% in the reconstruction group (p=0.002). In addition, the reconstruction group demonstrated significantly less patients that required second surgery (p=0.024). The only continuous variable that showed any statistically significant difference was the Insall-Salvati ratio (p=0.048) with the reconstruction group being a mean 1.3 versus a mean 1.4 in the neglect/ repair group. There was no difference was found for age, weight, BMI, Blackburn ratio, TDI, TT-TG, Pain, SANE, Kujala score, satisfaction, or length of follow-up.Conclusion:Medial patellofemoral ligament reconstruction in the setting of adolescent patellar instability with an intra-articular loose body results in significantly less recurrent instability and reduced need for subsequent surgery compared to those who do not undergo a concomitant ligament reconstruction.

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

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

WHAT ARE THE PREDICTORS OF POOR PATIENT-REPORTED OUTCOMES FOLLOWING SHOULDER INSTABILITY SURGERY?

Background:Prospectively-collected patient-reported outcomes (PROs) following shoulder instability surgery are limited. Attention has been drawn to standardizing these outcome measures in the adolescent literature.Hypothesis/Purpose:The purpose of this study was to evaluate which factors predict unfavorable PROs following shoulder instability surgery, including a “No” response to the Patient Acceptable Symptom State (PASS) question. We hypothesized that poor outcomes are associated with adolescent males, bone loss, larger labral tears, and articular cartilage injury.Methods:A cohort of patients age 13 years and older undergoing shoulder instability surgery were prospectively enrolled in point-of-care data collection at a single institution across 12 surgeons from 2015-2017. Demographics, ASES and SANE responses, and surgical findings were obtained at baseline. ASES, SANE, and PASS responses as well as revision surgery were queried at least one year post-operatively. Patients with isolated posterior labral tears and prior ipsilateral shoulder surgery were excluded. Regression analyses were performed.Results:A total 268 patients met inclusion criteria of which 201 completed follow-up responses (75%). Non-responders had a greater BMI, smaller proportion of glenoid bone loss, fewer Hill-Sachs lesions, and lower baseline ASES scores by 7.5 points (p < 0.05). Responders’ mean age was 25.5 years and 23% were female. Revision surgery occurred in 2.5% of these patients, and 81% responded “Yes” to PASS. A “Yes” response correlated to mean 31-point improvement in ASES and 34-point improvement in SANE scores. On univariate analysis, “No” responders were more likely to have a smoking history, a larger proportion of glenoid bone loss, and revision surgery (p < 0.05). However, on multivariate analysis, only combined labral tears (anterior/inferior plus superior or posterior tears) and injured capsules were associated with greater odds of responding “No” to PASS and with lower ASES and SANE scores (p ≤ 0.05) (Table 1). Age, sex, Hill-Sachs lesions, and grade III/IV articular cartilage injuries were not associated with variation in any PROs.Conclusion:In this prospective cohort, patients largely approve of their symptom state at one year or greater following shoulder instability surgery. A PASS “Yes” response occurred in 81% of patients and correlated to a clinically and statistically significant improvement in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across PROs, whereas age, sex, and Hill-Sachs lesions were not.Table:Table 1.Significant variables predicting PASS "No" responses, poorer ASES/SANE scores, and revision surgery. P values less than or equal to 0.05 are listed. VARIABLE CATEGORY PASS ASES SANE REVISION SURGERY SexMale (vs Female) Age- BMI- Years of Education- Smoking StatusQuit (vs Never) Current (vs Never)0.033 Baseline VR12 MCS- Glenoid Bone Loss<20% (vs None) >20% (vs None)0.004 Anchor Quantity- Labral Tear LocationSuperior(vs Anterior/Inferior) Combined(vs Anterior/Inferior)0.0500.0230.009 LateralityRight (vs Left) Hill-Sachs LesionYes, Engaging (vs No) Yes, Non-engaging (vs No) Capsule StatusInjured (vs Normal)0.0330.0030.0010.019Humeral and/or Glenoid Articular Cartilage InjuryGrade III/IV Lesion(vs Normal to grade II)

Comparison of MPFL Repair Versus MPFL Reconstruction for Refractory Patella Instability in Patients Under 18 Years Old

Background:The medial patellofemoral ligament (MPFL) is the primary soft-tissue restraint against lateral patellar displacement. Surgery to address MPFL incompetence is the current gold standard for recurrent patellofemoral instability. In the young patient, controversy remains regarding the role of MPFL repair in the setting of recurrent patella instability.Hypothesis/Purpose:Our purpose was to investigate subjective outcomes and complication profile of consecutive cohorts under age 18 undergoing MPFL repair or MPFL reconstruction. Our hypothesis was that the MPFL reconstruction group would have higher subjective outcome scores and a lower complication profile.Methods:Following IRB approval, a retrospective review of prospectively collected data identified a consecutive cohort of patients undergoing soft tissue stabilization for recurrent patella instability. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. MPFL repair was performed on patients prior to November 2015 and MPFL reconstruction with allograft from December 2015 to present. Patients undergoing concomitant bony realignment procedures were included. Patient reported outcomes (PROs) were collected including PROMIS, KOOS, IKDC, Marx, Tegner, and SANE scores. Complications requiring re-operation (i.e., infection, stiffness, recurrent instability) were recorded. Results were analyzed statistically.Results:The cohort was comprised of 43 patients (53 knees), with 15 males (34.9%), and 28 females (65.1%). The MPFL-Repair cohort had 22 patients (24 knees) and the MPFL-Reconstruction had 25 patients (29 knees). The average age of the MPFL-Repair cohort was 14.82 (range 10.5-17.8) and the average age of the MPFL-Reconstruction group was 15.59 (13.0-17.7). At final follow-up (minimum 6 months), there were no statistically significant differences between cohorts for KOOS Pain (p=0.4126), KOOS symptoms (p=0.7990), KOOS ADL (p=0.4398), KOOS Sport Rec (p=0.3357), KOOS QOL (p=0.8707), Global Physical Health (p=0.9736), Global Mental Health (p=0.1724), Physical Function (p=0.8077), Pain Interference (p=0.9740), Mobility T-Score (p=0.0634), Marx activity score (p=0.0844), Tegner Score (p=0.0752), IKDC (p=0.2646), and SANE score (p=0.0811). Regarding complications requiring re-operation, there was 1 knee in the MPFL-Reconstruction group (3.4%) that required further surgery (1 for fracture) and 9 knees in the MPFL-Iso cohort (37.5%) that required re-operation (1 for fracture, 8 for recurrent instability). The difference in complication rate was statistically significant (p=0.0012).Conclusion:In patients under 18 years old undergoing surgery for refractory patella instability, both MPFL allograft reconstruction and MPFL primary repair demonstrated no difference in subjective outcome scores at midterm follow-up. MPFL primary repair had significantly increased rate of complication requiring re-operation, particularly recurrent patella instability requiring revision to MPFL reconstruction.Tables/Figures:Table 1.1.KOOSSub-scaleSurgery Type>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundADLRepair89.4516.0782.3296.57220.4398Reconstruction92.529.0988.4996.5522PainRepair85.8515.8478.8392.88220.4126Reconstruction89.028.4285.2892.7522SportRepair66.5929.5453.5079.69220.3357Reconstruction73.6416.7066.2381.0422SymptomsRepair81.7316.3574.4888.98220.7990Reconstruction80.6411.3075.6385.6522QOLRepair60.8226.1049.2472.39220.8707Reconstruction61.9418.7953.6170.2722Table 1.2.PROMISSub-scaleSurgery Type>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundGlobal Physical HealthRepair50.3910.3744.4056.38140.9136Reconstruction50.097.1847.1952.9926Global Mental HealthRepair56.738.1152.0561.41140.1724Reconstruction52.2710.4048.0656.4726Pain Interference T-ScoreRepair52.279.6047.1557.38160.9740Reconstruction52.178.2248.8555.4926Physical FunctionT-ScoreRepair47.168.2442.7751.55160.8077Reconstruction47.787.9944.6250.9427MobilityT-TestRepair50.068.9843.1556.9690.0634Reconstruction43.317.1239.0147.6113Table 1.3.OtherVariableSurgery Type>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundMarxRepair7.106.124.249.96200.0844Reconstruction3.685.900.846.5319SANERepair62.7528.5547.5477.96160.0811Reconstruction75.5215.7868.7082.3523TegnerRepair5.213.033.756.67190.0752Reconstruction3.682.002.724.6519IKDCRepair70.0419.6259.5980.50160.2646Reconstruction63.7414.7057.2270.2622

OUTCOMES OF ARTHROSCOPIC LOOSE BODY MANAGEMENT IN PATELLA INSTABILITY: MEDIAL PATELLOFEMORAL LIGAMENT NEGLECT OR REPAIR VERSUS RECONSTRUCTION

Background: Patellar instability is common in adolescents during their growth. Management of the actual patellar instability at the time of arthroscopic treatment for concomitant intra-articular loose body has been debated since many surgeons will manage first-time dislocations without surgery. Hypothesis/Purpose: To demonstrate that medial patellofemoral joint reconstruction, rather than neglect or repair of the ligament, should be performed at the time of arthroscopic loose body removal for first-time patellar instability events in children. Methods: Retrospective study design was performed on all patients who sustained a patellar instability event that resulted in an intra-articular loose body between 2011 and 2017 at our institution. Data was collected using ICD-9/10 and/or CPT codes. Patients included in the analysis were required to have a minimum of 24 month follow-up documented. We then performed chart review and radiographic review (XR and MRI). Variables collected included: demographics, weight, BMI, pain score, SANE score, Kujala score, subsequent recurrent instability, need for second surgery, growth plate status, trochlear dysplasia, TT-TG, Insall-Salvati ratio, and Blackburne-Peel ratio. Data analysis pooled the “neglect” and “repair” groups together and compared it to the “reconstruction” group. Continuous variables were examined for normal distribution and homogeneity and analyzed with ANOVA or Mann Whitney. Chi square was utilized for categorical variables. Results: 64 patients (34 males, 30 females) with a mean age at surgery of 14 years (range 9 to 18) met criteria. These participants had a reported mean weight (kg) and BMI of 67.6 kg and 23.9, respectively. In our two-cohort analysis, the reconstruction cohort demonstrated significantly less subsequent instability, with the rate of recurrence being 58.7% in the neglect/repair compared to 16.7% in the reconstruction group (p=0.002). In addition, the reconstruction group demonstrated significantly less patients that required second surgery (p=0.024). The only continuous variable that showed any statistically significant difference was the Insall-Salvati ratio (p=0.048) with the reconstruction group being a mean 1.3 versus a mean 1.4 in the neglect/ repair group. There was no difference was found for age, weight, BMI, Blackburn ratio, TDI, TT-TG, Pain, SANE, Kujala score, satisfaction, or length of follow-up. Conclusion: Medial patellofemoral ligament reconstruction in the setting of adolescent patellar instability with an intra-articular loose body results in significantly less recurrent instability and reduced need for subsequent surgery compared to those who do not undergo a concomitant ligament reconstruction.

COMPARISON OF BONE-PATELLA TENDON-BONE (BTB) AND QUADRICEPS AUTOGRAFT FOR ACL RECONSTRUCTION IN PATIENTS UNDER 18 YEARS OF AGE

Background:Graft choice for ACL reconstruction in patients under 18 years old remains controversial. BTB autograft has long been considered for young athletes who are at or near skeletal maturity. Quadriceps autograft has emerged as an alternative graft choice in the young patient population. However, there remains a paucity of comparative outcomes.Hypothesis/Purpose:Our purpose is to compare subjective outcomes and complications of ACL reconstruction in patients under 18 years old using either BTB or quadriceps autograft. Our hypothesis is that there will be no difference in subjective outcome or complication between groups.Methods:Following IRB approval, retrospective review of prospectively collected data identified consecutive cohorts of patients under 18 years old undergoing ACL reconstruction with either BTB or quadriceps autograft. Surgery was performed by a single sports fellowship trained surgeon between 2011-2019. Patients undergoing concomitant osteotomies, cartilage restoration, and other ligament reconstruction procedures were excluded. Pre- and post-surgical patient reported outcomes (PROs) including IKDC, KOOS, PROMIS, SANE, Tegner, and Marx were compared between groups. Complications requiring re-operation (i.e., infection, stiffness, reconstruction failure) were recorded. Results were analyzed statistically.Results:71 patients met inclusion criteria. There were 41 BTB and 30 quadriceps autografts. Mean age was 16.5 years in the BTB group and 14.5 in the quadriceps group (p=0.0000006). 27 of 41 (66%) BTB and 13 of 30 (43%) quadriceps were female. There were no significant differences in PROs between groups. At minimum 6-month follow-up (range 6-25.7 months), patients in both quadriceps and BTB autograft cohorts reported statistically significant improvements in IKDC scores (31.10%, p=0.0009; 34.25%, p=0.00000008), all KOOS domains, SANE (41.80%, p=0.0000006; 42.42%, p=0.000000002), and Tegner scores (2.99%, p=0.0002; 3.35%, p=0.000004). Post-operative PROs were not significantly different between groups (p>0.05). Complications were low and not significant between groups. Both quadriceps and BTB autograft cohorts required 3 post-operative re-operations (10% and 7%, p=0.7), each group including 2 revision reconstructions (7% and 5%, p=0.8) and 1 procedure for stiffness (3% and 2%, p=0.8).Conclusion:For ACL reconstruction in patients under 18 years old, both BTB and quadriceps autografts demonstrated significant subjective improvements and low rates of complications requiring re-operation. Quadriceps autograft appears to be a safe and effective alternative to BTB autograft in this challenging patient population.Table 1.Pre-Operative PROsKOOSSub-scaleGraftPre-opNP-valueMeanSD95% CILower BoundUpper BoundADLQuadriceps75.1316.1372.4377.83170.425BTB79.1615.7777.0081.3225PainQuadriceps66.9919.5063.7370.26170.065BTB77.2014.9975.1179.3024SportQuadriceps38.8223.2934.9342.72170.806BTB40.6022.4737.5243.6825SymptomsQuadriceps63.4319.9160.1066.76170.713BTB65.5316.6563.2567.8125QOLQuadriceps28.6920.5025.2632.13170.229BTB36.0218.0733.5438.4925PROMISSub-scaleGraftPre-opNP-valueMeanSD95% CILower BoundUpper BoundPhysical HealthQuadriceps49.156.5348.0550.24170.332BTB51.246.0550.2652.2218Mental HealthQuadriceps57.597.5456.3358.85170.418BTB59.546.5158.4860.6018Physical FunctionQuadriceps39.525.7338.5640.48170.183BTB42.607.4941.3843.8118Pain InterferenceQuadriceps57.936.3356.8758.99170.892BTB58.278.2956.9259.6218MobilityT-ScoreQuadriceps40.916.5239.4642.36100.372BTB43.697.8742.2345.1414VariableGraft Pre-opNP-valueMeanSD95% CILower BoundUpper BoundMarxQuadriceps14.184.1413.4814.87170.964BTB14.203.2413.7614.6425SANEQuadriceps45.6526.5141.2150.08170.968BTB46.0024.8441.8450.1617TegnerQuadriceps2.471.422.232.71170.158BTB3.211.742.963.4524IKDCQuadriceps44.8315.0741.9247.74130.313BTB50.6316.3748.1253.1520OtherTable 2.Post-Operative PROsKOOSSub-scaleGraft>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundADLQuadriceps98.881.6798.6399.13210.326BTB97.864.4897.3398.4033PainQuadriceps94.576.7193.5795.58210.637BTB93.439.6492.2924.5733SportQuadriceps92.209.8790.7393.68210.108BTB83.6422.6180.9586.3233SymptomsQuadriceps91.438.9390.0992.77210.563BTB89.5912.5988.1091.0933QOLQuadriceps70.5419.6867.5973.49210.251BTB77.0420.4674.6479.4334PROMISSub-scaleGraft>6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundPhysical HealthQuadriceps58.307.9857.0759.53200.651BTB59.246.5258.4260.0530Mental HealthQuadriceps58.248.3356.9259.55190.131BTB61.837.7460.8762.8030Physical FunctionQuadriceps51.797.9950.5753.02200.205BTB55.3210.4954.0456.6131Pain InterferenceQuadriceps47.167.0446.1048.21210.589BTB46.007.8145.0446.9631MobilityT-ScoreQuadriceps53.987.5552.5855.38140.456BTB55.726.3454.8156.6323VariableGraft >6 Months Post-opNP-valueMeanSD95% CILower BoundUpper BoundMarxQuadriceps11.175.0210.1612.18120.572BTB12.225.2411.4712.9723SANEQuadriceps87.4410.6085.7289.17180.805BTB88.4214.5886.6390.2131TegnerQuadriceps5.462.405.005.92130.221BTB6.562.666.206.9225IKDCQuadriceps75.9326.3371.3880.47160.219BTB84.8816.3882.3787.4020Other

Revision of Anatomic Total Shoulder Arthroplasty to Hemiarthroplasty: Does it work?

The projected increase in revision shoulder arthroplasty has increased interest in the outcomes of these procedures. Glenoid component removal and conversion to a hemiarthroplasty (HA) is an option for aseptic glenoid loosening after anatomic total shoulder arthroplasty (aTSA). We identified patients who had undergone revision shoulder arthroplasty over a 15-year period. 17 patients met inclusion and exclusion criteria, and a retrospective chart review was conducted for pre-surgical and operative data. We contacted patients at a mean follow-up of 70 months from revision surgery for implant survival, reoperations and functional outcomes scores. Implant survival was estimated to be 88% at 2 years and 67% at 5 years. Mean ASES score for surviving implants was 58 ± 22. Mean SANE score was 54 ± 24, and mean VAS pain score was 3.5 ± 2.8. Mean SF-12 Mental and Physical scores were 46 ± 15 and 38 ± 10, respectively. Five patients (50% of those with surviving implants) reported being either very satisfied or satisfied with the status of their shoulder. There were complications in 6 patients (35%) and 5 patients (29%) required reoperation. HA following failed aTSA due to glenoid loosening produced modest clinical results and satisfaction rates. Reverse arthroplasty may be a more reliable treatment strategy in this patient population.

3:09 PM Abstract No. 4 ■ FEATURED ABSTRACT Arterial embolization of the shoulder for pain secondary to adhesive capsulitis: interim results from an investigational device exemption US trial

Adhesive capsulitis (AC) has been postulated to cause pain secondary to capsular neovascularization and accompanying nerve growth. Results from an initial overseas study of arterial embolization with an antibiotic were promising. We present our interim results from a prospective US Investigational Device Exemption pilot study evaluating arterial embolization of the shoulder (AES) with spherical embolic. Sixteen patients (14F, 2M: Mean age 52y) with adhesive capsulitis resistance to at least 30 days of conservative treatment were enrolled (NCT03676829). Included subjects had a visual analog scale (VAS) greater than 40 mm, and did not have prior shoulder replacement surgery, autoimmune disease, or complete rotator cuff tear All subjects were assessed before and after the procedure with MRI, VAS (0-100 mm), Single Assessment Numeric Evaluation (SANE, 0-100), and American Shoulder and Elbow Surgeons (ASES, 0-100) scores. Upper extremity angiography was performed in all subjects via radial artery access and six target arteries were selected when present. Embolization was performed with spherical embolic when hypervascularity was noted. Adverse Events (AE) were recorded at all follow-up time points. Neovascularity was identified in all patients by arteriography and AES was technically successful in all patients (16/16). A total of 64 arteries were embolized with 75-micron embolic. Baseline VAS, SANE, and ASES scores before the procedure for all 16 patients were 87.5 mm, 30.8, and 28.8 respectively. Eleven patients were eligible for 1-month follow-up at present and demonstrated significant improvement in VAS (pre/post mean = 89/32, P = 0.00003), SANE (pre/post mean = 32/60, P = 0.02), and ASES (pre/post mean= 29/59, P = 0.004). At 3 months, mean VAS was 13.3, SANE 82.9, and ASES 79.3. No major adverse events occurred. Transient skin discoloration around the treatment region was reported in 9 patients with complete resolution at 1-month follow-up. Interim results demonstrate that AES is an effective treatment for patients with AC refractory to conservative treatment.

Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference?

Background: Adolescent athletes are at risk of sustaining an injury to the posterior and superior labrum of the glenoid. Limited information is available regarding the outcomes of surgical intervention in this specific age cohort. Purpose: To compare those patients with pure posterior pathology and those with posterior labral tears that involve the biceps anchor (superior labrum anterior-posterior [SLAP] tears) to determine risks for failure in the surgical management. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on all patients under the age of 19 years over an 8-year period to identify those treated for superior and posterior labral pathology, followed by chart review, radiographic review, and arthroscopic findings. Patient characteristics and other variables were recorded, including cause (traumatic vs atraumatic), activity/sports (overhead vs nonoverhead), involvement of the biceps anchor—crossing the 12-o’clock position (posterior vs SLAP), associated pathologies, outcome scores (Single Assessment Numerical Evaluation [SANE] and Pediatric/Adolescent Shoulder Survey [PASS] scores), and complications. Results: Forty-eight patients (30 boys, 18 girls) with a mean age at surgery of 16.5 years (range, 13.5-19 years) were identified who met criteria, with a mean follow-up of 4.1 years (range, 1.3-6.9 years). Nineteen patients had SLAP tears and 29 patients had posterior tears. All but 2 regularly participated in sports at the time of their injury; of the athletes, 26 (56.5%) played an overhead sport and 20 (43.5%) played a nonoverhead sport. The cause of the injury was traumatic in 25 cases (52.1%) and atraumatic in 23 cases (47.9%). Outcome scores were not significantly different between cause or type of sports played; SANE scores were not significantly different by tear type (mean SLAP score, 88.4 compared with mean posterior score, 80.9; P = .124); but the mean PASS score in the SLAP group was 88.7, compared with 76.2 in the posterior group (P = .005) at final assessment. Only 1 SLAP patient had failed management (5.3%) compared with 5 patients in the posterior-only cohort (17.2%). Conclusion: Posterior SLAP tears have better outcomes and lower failure rates than posterior-only tears in the adolescent population. Posterior-superior labral tears can occur in all sports types with multiple causes, but the only factor that appears to play a role in ultimate outcome is whether the tear crosses under the biceps anchor to the anterior side.

The Impact of Workman’s Compensation on Recovery After Biceps Tenodesis

The purpose of this study is to compare the postoperative recovery outcomes of after isolated biceps tenodesis in patients with and without workman’s compensation claims. Workman’s compensation (WC) claims have been associated with poor outcomes after a variety of orthopedic surgery procedures, particularly when examining recurrent pain and function. However, the impact of WC on a variety of outcomes after shoulder surgery is not as well understood. Biceps tenodesis is a well-established treatment for isolated biceps or superior labrum pathology. However, the impact of factors, such as workman’s compensation have yet to be examined in depth Using the surgical outcomes system (SOS) database (Arthrex Inc., Naples, FL), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after isolated biceps tenodesis. The time points analyzed included, preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included visual analog score (VAS), American shoulder and elbow score (ASES), VR-12 mental and physical, simple shoulder test (SST), and SANE. Overall, 181 patients with WC claims underwent isolated biceps tenodesis, compared to 1,069 patients without WC claims. There were similar demographics and comorbidities in the two groups, including gender (34% females in WC vs 38% females in non-WC), age (mean 47 years in WC vs. 50 years in non-WC), smokers (15% in WC vs. 10% in non-WC), and diabetes (8% in WC vs. 6% in non-WC). The postoperative recovery curves for VAS, ASES, and SANE are displayed in Figure 1 below. Patients without WC claims had significantly improved VAS, VR-12, ASES, SANE, and SST scores at all times points after 3 months when compared to those with WC claims (p<0.001). However, given many with measures were significantly worse preoperatively in patients with WC claims, we also analyzed the preoperative to postoperative change in all outcomes at each time point. At 1 year when compared to those without WC claims, patients with WC claims had worse VAS (p=0.03), ASES (p=0.007), SANE (p<0.001), and SST (p=0.08) (Figure 2 below). When analyzing the patient’s recovery after isolated biceps tenodesis, workman’s compensation claims lead to significantly worse pain and functional outcomes at every major time point (3, 6, 12, and 24 months). Furthermore, the patients with WC also had worse preoperative to postoperative improvements in most of the outcomes. This information can be used to educate surgeons and patients on postoperative expectations, as well as analyses focused on health economics, value, and policy.