Significant Improvement In Shoulder Function Research Articles

Pre-operative transverse tendon thickness in small and mid-sized rotator cuff tears does not affect clinical outcomes after arthroscopic repair

IntroductionPrevious studies on rotator cuff tears have examined both clinical and radiographic parameters which may influence post-operative clinical outcomes. While rotator cuff tears are frequently classified by size or depth, there is currently no literature available examining the thickness of the remnant tendon, and its impact on post-operative outcomes. We hypothesize that decreased pre-operative transverse tendon thickness will result in poorer post-operative clinical outcomes. MethodsWe prospectively recruited patients who underwent arthroscopic repair of small to medium full-thickness rotator cuff tears. These patients were followed up for a minimum of 2 years post-operatively. Basic biodata, as well as Visual Analog Scale (VAS) for pain, Constant-Murley Score (CMS), UCLA Shoulder Score (USS), and Oxford Shoulder Score (OSS) at 3 different time points (pre-operatively, 1 year post-operatively, and 2 years post-operatively) were collected. Transverse tendon thickness was measured by independent blinded radiologists on pre-operative ultrasonographic images. Wilcoxon signed-rank test was used to compare outcome scores and multivariable robust linear model was fitted to assess the effect of transverse tendon thickness on post-operative scores. ResultsA total of 63 patients were enrolled in this study, predominantly female (65%) and had a median age of 72 years. Pre-operatively, the median transverse cuff thickness was 5.0 ​mm and median tear size was 1.4 ​cm. The median VAS at preoperative was 7, which reduced to 0 ​at 2 year post-operative, indicating statistically significant improvement in pain levels (p ​< ​0.001). Statistically significant improvement in shoulder function measured by CMS, UCLA score and OSS were also seen over time (p ​< ​0.001). Robust regression analysis revealed that transverse cuff thickness had no statistically significant effect on VAS (p ​= ​0.99), CMS (p ​= ​0.84), UCLA score (p ​= ​0.22), and OSS scores (p ​= ​0.73) at 2 years postoperatively. DiscussionPre-operative transverse tendon thickness of small- to mid-sized supraspinatus tears does not influence clinical outcomes after arthroscopic repair. Differences in transverse tendon thickness may have an association with tendon healing but do not translate to an association with post-operative outcomes in terms of pain, function, and patient-reported outcome measures. Level of evidenceIV.

Virtual Versus in-Person Physiotherapy Consultations Following Shoulder Pain

The purpose of this evaluation was to analyse and compare the outcomes of virtual physiotherapy consultations versus in-person physiotherapy consultations following shoulder pain. The outcomes of 104 patients (49 virtual vs. 55 in-person) were reviewed. Shoulder function and pain scores were captured. Comparative analysis was performed using a two-tailed Student’s t-test. Total number of physiotherapy sessions and patient satisfaction scores were also recorded. Both modes of consultations showed significant improvements in shoulder function and pain scores when analyse separately, and when compared virtual physiotherapy consultations led to significant improvements in shoulder function and in-person physiotherapy consultations led to significant improvements in pain scores. Future research should focus on randomised controlled trials to directly compare virtual physiotherapy consultations and in-person physiotherapy consultations to confirm the findings of this evaluation.

Coracoclavicular and acromioclavicular ligament reconstruction with a double-bundle semitendinosus autograft and cortical buttons for chronic acromioclavicular joint dislocations: clinical and imaging outcomes

BackgroundThere are few clinical and radiographic studies of coracoclavicular (CC) ligament reconstruction in chronic acromioclavicular (AC) joint dislocation. Additionally, reported AC joint reduction rates vary. HypothesisArthroscopically assisted double-bundle semitendinosus tendon autografts with CC and AC ligament reconstruction for AC joint reconstruction provide AC joint stability and improved function at the final visit. MethodsIn this retrospective study of prospectively collected data, 21 patients surgically treated for chronic AC joint dislocation (Rockwood III–V) were assessed clinically and radiographically preoperatively, and at day 1, 3 months, 12 months, and at a final visit (> 24 months) postoperatively. Clinical assessments included Constant and ASES scores. The CC vertical distance (CCD) on the affected and unaffected sides [CCD ratio (%)] on the anterosuperior view were measured. AC joint vertical reduction loss was defined as an increase in the CCD ratio of > 25%. Horizontal AC joint instability was evaluated on axillary views. Pearsons’ correlation coefficients were generated to examine the relationships among postoperative clinical scores, CCD ratio, interval from injury to surgery, and age at the time of surgery. ResultsTwenty-one shoulders in 21 patients (mean age, 40.0 years at the time of surgery; 16 men, 5 women) were evaluated with a mean 31.7-month follow-up period. The mean Constant scores, ASES scores, and CCD ratios significantly improved from preoperatively to the final visit [57.4 ± 10.1, 49.1 ± 12.1, 101.6 ± 64.1 preoperatively; 89.6 ± 5.3, 96.5 ± 4.2, 9.9 ± 34.5 at the final visit, respectively (P < 0.001 for all)]. Vertical AC and horizontal AC joint instability were observed in four shoulders (19.0%) and in one shoulder (4.8%), respectively. However, there was no significant correlation between the increase in CCD and clinical scores at the final visit (Constant score; r = 0.179, P = .438: ASES score; r = -0.260, P = .256) or the interval from injury to surgery (r = 0.099, P = .669) or age at the time of surgery (r = 0.019, P = .935). No clinical complications were associated with clinical symptoms. ConclusionsPatients who underwent the index procedure achieved significant improvement in shoulder function without complications related clinical symptom after a mean follow-up interval of 31.7 months. In contrast, the rates of total ACJ instability in the vertical and horizontal planes were unsatisfactory but compatible with those in previous studies.

Cemented vs. press-fit humeral stems: a matched cohort analysis at a mean follow-up of 10 years

IntroductionWhile cementation of humeral stems has long been considered the gold standard for anatomic shoulder arthroplasty (aTSA), cementless, or press-fit, fixation offers a relatively cheaper and less demanding alternative, particularly in the setting of a revision procedure. However, this approach has been accompanied by concerns of implant loosening and high rates of radiolucency. In the present study we performed a propensity matched comparison of clinical and patient-reported outcomes between cemented and cementless fixation techniques for aTSA. MethodsThis study was a retrospective comparison of 50 shoulders undergoing aTSA: 25 using cemented humeral fixation versus 25 using press-fit humeral fixation. Patients in the two groups were propensity matched according to age, sex, and preoperative ASES score. Primary outcome measures included range of motion (ROM) (forward elevation, external rotation, internal rotation), patient reported outcomes (American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), Visual Analog Scores (VAS)), and implant survival. ResultsAt baseline, the two fixation groups were similar in regard to age, sex, BMI, preoperative ASES score, and surgical indication. Mean follow-up was 11.7 ± 4.95 years in the cemented cohort and 9.13 ± 3.77 years in the press-fit cohort (p=0.045). Both groups demonstrated significant improvements postoperatively in all included ROM and patient-reported outcomes. However, press-fit patients reported significantly better VAS, ASES, and SST scores. Mean VAS pain score was 1.1 ± 1.8 in press-fit patients and 3.2 ± 3.0 in cemented patients (p=0.005). The mean ASES score was 87.7 ± 12.4 in press-fit patients and 69.5 ± 22.7 in cemented patients (p=0.002). Lastly, the mean SST score was 9.8 ± 3.1 in press-fit patients and 7.7 ± 3.7 in cemented patients (p=0.040). Both fixation techniques provided lasting implant survivorship with only a single revision operation in each of the cohorts. ConclusionHerein, we provide a propensity matched, long-term comparison of patients receiving anatomic shoulder arthroplasty stratified according to humeral stem fixation technique. The results of this analysis illustrate that both types of humeral fixation techniques yield durable and significant improvements in shoulder function with similar rates of survival at 10 years of follow-up.

Short- to medium-term outcomes and future direction of reverse shoulder arthroplasty: Current concepts

Reverse shoulder arthroplasty is typically indicated for patients with severe shoulder osteoarthritis, rotator cuff tear arthropathy, or proximal humerus fractures that have failed to heal properly. The primary goal of reverse shoulder arthroplasty is to improve shoulder function and reduce pain, while also restoring the ability to perform daily activities.There is a growing body of evidence supporting the effectiveness of reverse shoulder arthroplasty in improving shoulder function and reducing pain in patients with severe shoulder osteoarthritis or rotator cuff tear arthropathy. Reverse shoulder arthroplasty is associated with significant improvements in shoulder function and pain reduction compared to non-surgical treatments.This paper aims to summarize current knowledge, practices and present a summary of the long-term effects of reverse shoulder arthroplasty (RSA) on patient outcomes, including how these outcomes are defined and what measures are typically used to assess them. It will also cover newer definitions of outcomes for RSA that have been developed in recent years in order to better understand the long-term effects of the procedure on patient-reported outcomes and functional ability, as well as information on revision surgery and implant survivorship, and the future of RSA (3D-navigation, patient-specific instrumentation, robotics and artificial intelligence) and its effects on outcomes.

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

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

Return-to-work following shoulder arthroplasty in adults with osteoarthritis.

Anatomic total shoulder arthroplasty (aTSA) and hemiarthroplasty (HA) have demonstrated significant improvement in shoulder function and pain relief. Work-related outcomes have become increasingly important, while the current literature lacks evidence related to return-to-work (RTW) and which factors might have an influence on it. This study aimed to assess RTW in patients who have received aTSA or HA at a minimum of 1-year follow-up after surgery, and secondary to evaluate possible prognostic factors associated with RTW. We performed a retrospective query in employed patients diagnosed with primary osteoarthritis of the shoulder, who received either an aTSA or HA between February 2006 and February 2021. Preoperative and post-operative work and sports participation were assessed. Forty-four patients participated in this study (98% compliance), of which 40 patients (91%) were able to RTW at a median time of two (interquartile range: 2-4) months post-operatively. Patients with a medium-/high-demand occupation demonstrated RTW at a significantly lower rate (79%) than those with light-demand occupations (100%; P = 0.03). There was a statistically significant association between return to full employment and patients' expectation to fully return, absence of preoperative work adjustments and preoperative sick leave (odds ratio: 16.9 [3.1-93.5]; 18.3 [2.1-160.4]; 0.1 [0.0-0.6]). aTSA and HA facilitate excellent RTW rates. Patients with a medium-/high-demand occupation return at a significantly lower rate. The ability to RTW seems to be multifactorial and the results found might not be attributed to shoulder arthroplasty alone.

Subacromial Platelet-Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy

The purpose of this study was to compare the effect of subacromial leukocyte-rich PRP injections in patients with isolated rotator cuff tendinopathy (RCT) and those with partial thickness rotator cuff tears (PTRCTs) based on functional outcomes, pain improvement, sleep disturbances, and return to sports. Between November 2019 and March 2021, 150 patients underwent PRP injections at our institution for refractory rotator cuff tendinopathy and partial rotator cuff tears (105 RCTs and 45 PTRCTs). The American Shoulder and Elbow Surgeons (ASES) score, the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE) and The Pittsburgh Sleep Quality Index were evaluated at 2, 6 and 12 month follow up. Return to sports was also evaluated. An ultrasound examination was performed to evaluate structural outcomes 12 months after the injection. The mean age was 36.6 years (±9.08). Overall, the ASES, VAS, SANE and Pittsburgh scores showed statistical improvement after the injection (P < .01). Specifically, the improvement in the ASES score which was the primary outcome measure was significantly greater in the group without tears than in the group with PTRCTs at all follow-up times. Moreover, 94% of the patients in the isolated RCT group and 49% in the PTRCTs group achieved a substantial clinical benefit at 12 months follow up. Ten out of the 50 patients (20%) who received PRP injections due to a partial RC tear underwent surgery due to lack of clinical improvement. Subacromial PRP injections produced a significant improvement in shoulder function, pain and sleep disturbances in most patients with RCT refractory to conservative treatment that was maintained up to 12-month follow-up. Moreover, most patients returned to sports at the same level they had previous to the injury. However, improvement in symptoms and functional outcomes were significantly worse in patients who had a PTRCT compared with patients who had an isolated tendinopathy.

Paper 17: Minimum 5-year Clinical Outcomes of Arthroscopically Repaired Massive Rotator Cuff Tears – Effect of Age on Clinical Outcomes

Objectives: Massive rotator cuff tears (MRCTs) are a frequent and challenging entity encountered by for orthopedic surgeons, accounting for up to 40% of all rotator cuff tears (RCT). Furthermore, the efficacy of repair of MRCTs in older patients is questioned by some. The purpose of this study is to report minimum 5-year outcomes after primary arthroscopic rotator cuff repair (ARCR) of MRCT and the effect that age has on outcomes. We hypothesized that there would be low rates of revision and a high patient satisfaction in a mid-term follow up in those patients treated with a primary ARCR independent of age. Methods: Data was collected prospectively and retrospectively reviewed for this IRB approved study. Inclusion criteria was that patients were a minimum of 5 years out from an ARCR of a MRCT by a single surgeon from February 2006 to November 2016. Patients were excluded if they had glenohumeral osteoarthritis (Hamada &gt;2), fatty infiltration (Goutallier &gt;3), or if they had concomitant pathologies such as labral lesions or chondromalacia that led to additional surgical procedures except for biceps tenodesis/tenotomy and subacromial decompression. MRCTs were defined by the Neer Circle’s Delphi consensus statement as tendon retraction to the glenoid rim and/or a minimum exposed greater tuberosity of at least 67 percent in combination with the Gerber classification of at least two affected tendons. Patient reported outcome (PRO) data was collected preoperatively and evaluated at a minimum follow-up of 5 years postoperatively using the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS), and patient satisfaction to assess surgical outcomes at final follow-up. Linear and LOESS regression in addition to correlation was analyzed to assess the effect of age on clinical outcomes. Further, a sub-group analysis of patients over and under 65 was performed. Retears, revision surgery, and surgical complications were recorded. Surgical failure was defined as revision surgery. Results: In total, 188 patients with ≥ 2 tendon RCTs who were at least 5 years out from surgery were identified. After application of exclusion criteria and the Neer Circle’s MRCT definition, 61 patients (mean age: 59.5 years, range: 39.6-73.8; 38 males, 23 females) with a mean follow up of 7.9 years (range 5.0-12.1) included in this study. Final follow-up was obtained in 44 patients (76%). At final follow-up, the mean PROs were significantly improved over preoperative levels for all PROs. The ASES scores improved from 59.4 to 95.0 (p&lt;.001), SANE improved from 66.3 to 89.9 (p&gt;.001), QuickDASH improved from 34.2 to 8.3 (p&lt;.001) and SF-12 PCS improved from 41.5 to 51.3 (p&lt;.001). Median postoperative satisfaction was 10 (range 1-10). Linear and LOESS regression analysis as well as correlation analysis showed that no PRO measures (ASES, SANE, QuickDASH, SF12-PCS, or patient satisfaction) were significantly associated with age at time of surgery. In the subgroup analysis of over and under 65, no significant differences between groups were demonstrated for PROs with the exception of postoperative SF-12 PCS (53.6 vs. 49.1; p=.041). Conclusions: The most important finding in this study is that patients undergoing ARCR of MRCTs experience significant improvements in shoulder function irrespective of patient age.

Subacromial Balloon Spacer for Massive Irreparable Rotator Cuff Tears

Massive irreparable rotator cuff tears (MIRCTs) represent 10% to 40% of cases of rotator cuff abnormality and are challenging to treat. When MIRCTs are unresponsive to nonoperative treatment, surgery may be considered. An arthroscopically inserted biodegradable subacromial balloon spacer (InSpace; Stryker) has grown in popularity in recent years for treatment of patients with MIRCTs. The balloon spacer is made of a copolymer of poly-L-lactide-eco-ε-caprolactone and is expected to fully resorb within 12 months after implantation. Research has suggested the balloon spacer becomes progressively compressed and is slowly replaced with fibrous tissue between the humeral head and the acromion, which may support a prolonged benefit following resorption. Clinical benefits may be achieved through reduced acromiohumeral abutment and subacromial friction during shoulder movement by lowering the humeral head and facilitating humeral gliding. The primary population indicated for use of the implant are patients older than 40 years with persistent shoulder pain and functional disability due to MIRCTs. Contraindications include irreparable subscapularis tears, moderate to severe arthritis, axillary nerve palsy, and known allergy to the implant material. There are not clear indications for use of the implant for treatment of partial-thickness tears or repairable complete rotator cuff tears. Familiari et al. reported that treatment with the balloon spacer was associated with a significant improvement in shoulder function, limited need for revision surgery, and high satisfaction at mean 3-year follow-up. More recently, a prospective multicenter randomized controlled trial was conducted to evaluate the efficacy and safety of the balloon spacer in 93 patients compared to 91 patients undergoing arthroscopic partial repair. Significant and clinically relevant improvements in the American Shoulder and Elbow Surgeons score from baseline were noted in both groups up to the 2-year follow-up.

Mini-open Rotator Cuff Repair Can Still Be a Good Surgical Technique to Repair a Rotator Cuff

Background: The clinical outcomes of rotator cuff repair (RCR) surgeries vary because each method has its own advantages and limitations. Objectives: This study aimed to compare the short-term outcomes of arthroscopic RCR (ARCR) and mini-open RCR (MRCR). Methods: In this study, we included 49 patients with a diagnosis of full rotator cuff tear who had undergone ARCR and MRCR at Poursina Hospital of Rasht and Akhtar Hospital of Tehran from 20 March 2017 to 20 March 2020. The patients were divided into ARCR (n = 24) and MRCR (n = 25) groups. The two surgical procedures were compared with each other before surgery and three and six months after surgery in terms of shoulder function based on UCLA, disability based on QUICKDASH, range of motion (ROM), and pain based on Visual Analogue Scale (VAS). Data were analyzed by chi-square, independent t-test, and repeated measures analysis of variance (ANOVA). Results: There were no differences between the groups in terms of demographic details. The mean duration of surgery was significantly higher in the ARCR group compared to MRCR group (125.5 vs. 70.42 minutes). The short-term outcomes in the two groups on three measurement occasions showed a significant improvement in shoulder function, disability, and ROM in both groups along with a reduction in pain severity (P &lt; 0.05); however, there was no significant difference between the two groups on any of the three occasions (P &gt; 0.05). Conclusions: Shoulder function, disability, ROM, and pain were not different between the two groups, but duration of surgery was less in MRCR group. Therefore, under the same conditions, MRCR is a better choice than ARCR due to its short duration of surgery.

Home-based exercise therapy for treating shoulder instability in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders. A randomized trial

Purpose To investigate the effectiveness of two home-based exercise programs for treating multidirectional shoulder instability (MDI) in patients diagnosed with Hypermobile Ehlers-Danlos syndrome (hEDS) or Hypermobility Spectrum Disorders (HSD). Methods Twenty-one hEDS/HSD patients with MDI were recruited from the Center for Medical Genetics of the Ghent University Hospital. Patients were randomly assigned to either the experimental or the control group. Both groups received a 6-month home-based exercise program. The primary outcome measure was the Western Ontario Shoulder Index (WOSI). Secondary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH), Tampa Scale for Kinesiophobia (TSK), Patient-Specific Functional Scale (PSFS), Global Rating of Change (GROC), and pain pressure thresholds. Outcomes were assessed at baseline, after 6 weeks, 12 weeks, and 24 weeks. Results Significant main effects for time were observed for all questionnaires, except for the TSK (p = 0.12). Patients improved 240 and 325 points on the WOSI after 12 (p = 0.02) and 24 weeks (p = 0.001), respectively. Additionally, patients improved 8.6 points on the DASH (p = 0.002), 4.3 points on the PSFS (p = 0.01), and 1.02 points on the GROC (p = 0.001) after 24 weeks. Conclusion No significant differences were found between group A and B. Both home-based exercise programs led to significant improvements in shoulder function. IMPLICATIONS FOR REHABILITATION Home-based exercise therapy may be effective for treating MDI in the hEDS/HSD population. Home-based training is beneficial for improving shoulder function, but a multidisciplinary, supervised approach might be more effective for altering kinesiophobia in this patient population.

Isokinetic and functional shoulder outcomes after arthroscopic capsulolabral stabilization

IntroductionShoulder stability is secured by dynamic and static stabilizers. Rotator cuff is responsible for dynamic stabilization. In cases of shoulder instability their activity is disturbed. Capsulolabral repair restores mainly static stabilization. This surgery treatment technique of shoulder instability was first described by Bankart in 1923. His idea, with further modifications, is commonly used up to this day. Evaluation of muscle shoulder recovery after stabilization should be one of the important criteria to allow patient to return to sport and work. However, not much isokinetic assessment after capsulolabral repair was described. The aim of this study were the following: the comparative assessment of the shoulder rotatory strength in patients following arthroscopic capsulolabral repair of unilateral anterior traumatic instability and clinical assessment with comparison of pre and post-operative results.Material and methodsForty-five patients, 14 women and 31 men, with an average follow-up of 4.4 years were tested bilaterally for internal and external rotation strength at four angular velocities. ASES and UCLA tests were collected before and after surgery.ResultsThe values of peak moment and muscle power parameters were slightly lower for an operated shoulder in comparison to a healthy shoulder for the external rotation. Total work parameter in external rotation was significantly lower for the operated shoulder in comparison to the non-operated side. The internal/external muscle group balance was lower for the operated shoulder in comparison to reference values in the women group. Furthermore, both ASES and UCLA scores were significantly higher after operation.ConclusionsAfter arthroscopic capsulolabral shoulder stabilization, slight differences in isokinetic evaluation, especially in external shoulder rotation, occur. It affects rotators muscle balance. In functional evaluation significant improvement in shoulder function occurs.

Significant Improvement in Shoulder Function and Pain in Patients Following Biologic Augmentation of Revision Arthroscopic Rotator Cuff Repair Using an Autologous Fibrin Scaffold and Bone Marrow Aspirate Derived From the Proximal Humerus

PurposeTo clinically evaluate patients who underwent a biologic augmentation technique in revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated stem cells isolated from bone marrow aspirate (BMA) obtained from the proximal humerus.MethodsThis is a retrospective review of prospectively collected data from patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and BMA obtained from the proximal humerus between 2014 and 2015. Minimum follow-up was 12 months. Outcome measures were collected preoperatively and postoperatively including range of motion as well as American Shoulder and Elbow Surgeons Shoulder Form, Simple Shoulder Test, single assessment numeric evaluation, and visual analog score. In addition, BMA samples of each patient were assessed for the number of nucleated cells and colony-forming units. Regression analysis was performed to investigate whether the number of nucleated cells and colony-forming units had an influence on outcome and failure.ResultsTen patients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA obtained from the proximal humerus between 2014 and 2015 were included. The mean follow-up time was 30.7 (range: 12-49) months. Four patients were revised at final follow-up. Postoperative clinical scores improved significantly: American Shoulder and Elbow Surgeons (28.1 ± 5.4 to 60.9 ± 9.0; P < .01), single assessment numeric evaluation (6.6 ± 2.3 to 65.1 ± 10.9; P < .01), visual analog scale (7.2 ± 0.9 to 3.1 ± 0.9; P < .01), and Simple Shoulder Test (1.6 ± 0.5 to 10.3 ± 5.7; P < .01). Postoperative range of motion increased significantly with regard to flexion (97.0 ± 13.6 to 151.0 ± 12.2; P < .01) and abduction (88.0 ± 14.0 to 134.0 ± 15.1; P = .038) but not with external rotation (38.0 ± 5.7 to 50.5 ± 6.5; P = .16). Less pain was correlated to an increased number of nucleated cells (P = .026); however, there was no correlation between failure rate and number of nucleated cells (P = .430).ConclusionsPatients who underwent biologic augmentation of revision arthroscopic rotator cuff repair using an autologous fibrin scaffold and concentrated BMA demonstrated a significant improvement in shoulder function along with reduction of pain. However, the overall revision rate for this procedure was 40%.Level of EvidenceLevel IV, therapeutic case series.

Survival of stemless humeral head replacement in anatomic shoulder arthroplasty: a prospective study

The long-term results of shoulder arthroplasty using stemless humeral head components with a mean follow-up period > 10 years were not available until now. The aim of this study was to evaluate the long-term results of shoulder arthroplasty using a stemless humeral head component. Since 2005, we have documented stemless humeral head replacement prospectively. Seventy-five patients with a mean age of 57 years at surgery (40 hemi-shoulder arthroplasties [HSAs] and 35 total shoulder arthroplasties [TSAs], 38 women and 37 men) were clinically and radiologically followed up after a mean period of 126 months (range, 105-157 months). Functional results were documented using the age- and sex-normalized Constant-Murley score (CMS) (ie, relative CMS). The relative CMS improved significantly (P < .0001) from 56% preoperatively to 90% postoperatively. Its subcategories of pain (8 points preoperatively vs. 12 points postoperatively, P < .0001), activities of daily living (10 points vs. 15 points, P < .0001), range of motion (20 points vs. 29 points, P < .0001), and strength (7 points vs. 11 points, P = .011) improved significantly as well. There was no significant difference in preoperative CMS vs. postoperative CMS, as well as its subcategories, between HSA (44.8 points vs. 67.1 points, P < .0001) and TSA (44.4 points vs. 68.9 points, P = .004). Clinically and radiologically, we observed no loosening of the stemless humeral head component. Stress shielding around the humeral component was not detected. Upward migration of the humeral head was observed in 17.5% of patients (21.6% with HSA and 11.5% with TSA, P = .303). No implant failure was observed on the humeral side. At follow-up, 18.3% of patients had rotator cuff deficiency (13.9% with HSA and 25% with TSA, P = .280). Overall, 9.3% of stemless shoulder arthroplasties were revised to reverse TSAs (5% of HSAs and 14.3% of TSAs, P = .097). TSA showed a trend for a higher revision rate than HSA. Secondary glenoid wear occurred in 64.3% of HSAs, and none of the HSAs were converted to TSAs. We observed an incomplete radiolucent line < 2 mm in 30.4% and glenoid loosening in 11.4% of cemented glenoid components. Kaplan-Meier analysis revealed a 10-year survivorship rate of 96.5% and an estimated 13-year survivorship rate of 90.1% for stemless humeral components. Stemless humeral head replacement showed no loosening and a significant improvement in shoulder function after a mean period of 11 years. The long-term clinical and radiologic results as well as the survivorship of anatomic shoulder arthroplasty using a stemless humeral head implant are comparable to the long-term results of standard stemmed anatomic shoulder arthroplasty.

Subacromial Balloon Spacer for Massive, Irreparable Rotator Cuff Tears Is Associated With Improved Shoulder Function and High Patient Satisfaction

To investigate associations between clinical and demographic parameters and Constant-Murley (CM) scores after subacromial balloon placement for massive, irreparable rotator cuff tears and to evaluate implant survival, shoulder function, and patient satisfaction. We prospectively analyzed patients with rotator cuff tears deemed irreparable on preoperative magnetic resonance imaging for whom nonoperative therapy was unsuccessful and who underwent balloon placement from 2014 to 2017 with minimum 1-year follow-up. Shoulder function was assessed using the CM score and the 12-Item Short Form Health Survey. The study included 51 patients (22 women and 29 men) with a mean age at surgery of 63 years (range, 50-78 years). The mean follow-up period was 36 months (range, 24-56 months). The postoperative acromiohumeral interval and total preoperative CM score predicted the postoperative CM score at final follow-up. The implant survival rates were 92% at 6 and 12 months, 90% at 2 years, and 87% at 3 and 4 years. Five patients underwent reverse total shoulder arthroplasty, and 1 underwent latissimus dorsi tendon transfer. Postoperatively, mean CM scores (± standard deviation) improved for range of motion (from 11 ± 5.4 to 34 ± 6.8) and strength (from 13± 5.4 to 28 ± 12) (P < .01 for both). The total CM score improved from 27 ± 7.4 preoperatively to 77 ± 15 postoperatively (P < .01). The physical and mental component summary scores on the 12-Item Short Form Health Survey improved from 27 ± 5.0 to 51 ± 6.5 (P= .02) and from 44 ± 15 to 56 ± 8.0, respectively (P < .01). Thirty-eight patients reported excellent satisfaction, 8 were satisfied, and 5 were dissatisfied. Of the patients, 50 (98%) exceeded the minimal clinically important difference (≥10.4) and patient acceptable symptom state (≥44). At mean 3-year follow-up, subacromial balloon spacer placement for massive, irreparable rotator cuff tears was associated with a significant improvement in shoulder function, limited need for revision surgery, and high patient satisfaction. A greater postoperative acromiohumeral interval and lower preoperative CM score predicted a lower postoperative CM score at final follow-up. Level IV, retrospective cohort study and treatment study.

Graft Tensioning in Superior Capsular Reconstruction Improves Glenohumeral Joint Kinematics in Massive Irreparable Rotator Cuff Tears: A Biomechanical Study of the Influence of Superior Capsular Reconstruction on Dynamic Shoulder Abduction.

Background:Superior capsular reconstruction (SCR) for massive, irreparable rotator cuff tears has become more widely used recently; however, ideal tensioning of the graft and the influence on joint kinematics remain unknown.Purpose/Hypothesis:The purpose of this study was to assess the effects of graft tensioning on glenohumeral joint kinematics after SCR using a dermal allograft. The hypothesis was that a graft fixed under tension would result in increased glenohumeral abduction motion and decreased cumulative deltoid forces compared with a nontensioned graft.Study Design:Controlled laboratory study.Methods:A total of 10 fresh-frozen cadaveric shoulders were tested using a dynamic shoulder simulator. Each shoulder underwent the following 4 conditions: (1) native, (2) simulated irreparable supraspinatus (SSP) tear, (3) SCR using a nontensioned acellular dermal allograft, and (4) SCR using a graft tensioned with 30 to 35 N. Mean values for maximum glenohumeral abduction and cumulative deltoid forces were recorded. The critical shoulder angle (CSA) was also assessed.Results:Native shoulders required a mean (±SE) deltoid force of 193.2 ± 45.1 N to achieve maximum glenohumeral abduction (79.8° ± 5.8°). Compared with native shoulders, abduction decreased after SSP tears by 32% (54.3° ± 13.7°; P = .04), whereas cumulative deltoid forces increased by 23% (252.1 ± 68.3 N; P = .04). The nontensioned SCR showed no significant difference in shoulder abduction (54.1° ± 16.1°) and required deltoid forces (277.8 ± 39.8 N) when compared with the SSP tear state. In contrast, a tensioned graft led to significantly improved shoulder abduction compared with the SSP tear state (P = .04) although abduction and deltoid forces could not be restored to the native state (P = .01). A positive correlation between CSA and maximum abduction was found for the tensioned-graft SCR state (r = 0.685; P = .02).Conclusion:SCR using a graft fixed under tension demonstrated a significant increase in maximum shoulder abduction compared with a nontensioned graft; however, abduction remained significantly less than the intact state. The nontensioned SCR showed no significant improvement in glenohumeral kinematics compared with the SSP tear state.Clinical Relevance:Because significant improvement in shoulder function after SCR may be expected only when the graft is adequately tensioned, accurate graft measurement and adequate tension of at least 30 N should be considered during the surgical procedure. SCR with a tensioned graft may help maintain sufficient acromiohumeral distance, improve clinical outcomes, and reduce postoperative complications.

Superior capsular reconstruction using a porcine dermal xenograft for irreparable rotator cuff tears: outcomes at minimum two-year follow-up

To evaluate midterm outcomes of arthroscopic superior capsular reconstruction (SCR) using a decellularized porcine dermal xenograft in patients with massive, irreparable rotator cuff tears and to determine the influence of concomitant, repairable subscapularis tears. This is a retrospective study of 56 patients with a minimum 2-year follow-up. Preoperative and postoperative range of motion, American Shoulder and Elbow Surgeonsscore, Subjective Shoulder Value, and visual analog score for pain were measured. Postoperative data were collected at 3, 6, 12, 24, and 36 months. Of the 56 patients who underwent arthroscopic SCR, there were 39 men and 17 women. The mean age at operation was 65 ± 9 years, and the mean follow-up was 34 ± 8 months. The mean preoperative American Shoulder and Elbow Surgeons improved from 41 ± 19 to 78 ± 18 at 24 weeks, to 86± 16 at 12 months, and to 90±9 at 24 months, P < .0001. Similarly, the mean preoperative Subjective Shoulder Value improved from 39 ± 17 to 74 ± 18 at 24 weeks, to 80 ± 18 at 12 months, and to 80 ± 11 at 24 months, P < .0001. The mean preoperative visual analog score improved from 6.5 ± 2.1 to 1.4 ± 2.2 at 24 weeks, to 0.7± 1.1 at 12 months, and to 0.2 ± 0.4 at 24 months, P < .0001. There were no differences in outcome scores between patients with intact vs. repaired subscapularis. Similarly, no statistically significant differences were found in forward flexion or external rotation after SCR between patients with an intact vs. repaired subscapularis. Failure of the SCR graft was observed on magnetic resonance imaging in 14 patients, 4 of whom opted for revision to reverse shoulder arthroplasty. Eleven patients were truly pseudoparalytic before surgery; in 5 cases, pseudoparalysis was reversed after SCR. SCR can alleviate pain and disability from irreparable rotator cuff tears and provide significant improvements in shoulder function; however, the xenograft technique resulted in inconsistent reversal of true pseudoparalysis. No difference was found between patients who required concomitant subscapularis repair vs. those who did not.

Anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allograft is effective for chronic acromioclavicular joint injuries at mid-term follow-up.

To evaluate the clinical and radiographic outcomes of patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allografts for the treatment of chronic acromioclavicular joint (ACJ) injuries with a minimum 1-year follow-up. Patients who underwent ACCR for chronic ACJ injuries between 2003 and 2017 were analyzed. Clinical outcome measures included American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM), Simple Shoulder Test (SST), and Single Assessment Numerical Evaluation (SANE) scores. Radiographic loss of reduction during follow-up was evaluated by calculating the difference (mm) in the coracoclavicular distance (CCD) of the involved side immediately postoperatively and at terminal follow-up. Forty-two patients (mean age: 42.7 ± 12.8years) were included in the study with an average follow-up of 3.8 ± 3.1years (range: 1.1-11.5years). Patients achieved significant improvement in ASES (50.2 ± 20.1 pre to 85.2 ± 16.3 post), CM (60.2 ± 18.5 pre to 88.2 ± 9.1 post), SST (6.1 ± 3.2 pre to 9.5 ± 3.7 post), and SANE (24.0 ± 25.7 pre to 89.0 ± 12.7 post) scores (P < 0.001, respectively). There were no significant differences in functional improvement when comparing type III and V injuries (n.s.). Mean increase in CCD of the involved side from immediately postoperative to final radiographic follow-up was 4.1 ± 3.9mm, with no significant correlation to clinical outcomes scores. Complications occurred in 33.3% of cases, with postoperative heterotopic ossification being most frequent (14.3%). Patients undergoing ACCR using free tendon allografts for chronic ACJ injuries achieved significant improvement in shoulder function at a mean follow-up of 3.8years. No correlation was observed between the amount of loss of reduction and clinical outcome scores. Free tendon allografts may be a reliable alternative to autografts in the treatment of chronic ACJ dislocations. IV.

Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique.

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up. All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016). Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246-253.