Single Assessment Numeric Evaluation Score Research Articles

Association Between Symptoms of Anxiety and Depression, Hip Pathology, and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement.

In patients with femoroacetabular impingement (FAI), mental health has been implicated in both symptom severity and postoperative outcomes. However, there are limited data regarding the independent influences of baseline mental health and hip pathology on patient-reported outcomes over time after hip arthroscopy. To evaluate the association between mental health and structural hip pathology with pain, hip function, and quality of life (QOL). Cohort study; Level of evidence, 3. Patient records from a single surgeon's hip outcomes registry were retrospectively reviewed. Mental health was evaluated using the Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores. Pain was evaluated with the Single Assessment Numeric Evaluation score for Activities of Daily Living (SANE-ADL), while hip-related QOL was evaluated with the 12-item International Hip Outcome Tool (iHOT-12). Hip function was assessed with the Hip Outcome Score (HOS) Sport-Specific (SS) and ADL subscales. Separate mixed models were used to predict pain, QOL, and hip function, including hip pathology measures (size of labral tear, grade of chondral damage, preoperative alpha angle), anxiety, depression, and time as fixed effects and individuals as a random effect. A total of 312 patients were included in this study. The preoperative alpha angle, degree of intraoperative cartilage damage, and size of the labral tear were not associated with pain or QOL (P > .05 for all). However, higher levels of anxiety and depression were significantly associated with lower SANE-ADL scores (estimate ± SE) (anxiety: -0.59 ± 0.07, P < .0001; depression: -0.64 ± 0.08, P < .0001), iHOT-12 scores (anxiety: -0.72 ± 0.07, P < .0001; depression: -0.72 ± 0.08, P < .0001), HOS-SS scores (anxiety: -0.68 ± 0.09, P < .0001; depression: -0.57 ± 0.10, P < .0001), and HOS-ADL scores (anxiety: -0.43 ± 0.05, P < .0001; depression: -0.43 ± 0.06, P < .0001). Patients had similar improvements in pain scores, QOL, and hip function after hip arthroscopy for FAI irrespective of their degree of hip pathology. Additionally, preoperative symptoms of anxiety and depression symptoms were associated with greater pain, decreased QOL, and worse hip function both pre- and postoperatively, independent of the degree of hip pathology. This suggests that efforts to directly address symptoms of anxiety and depression may improve outcomes after hip arthroscopy.

Percutaneous bone marrow concentrate and platelet products versus exercise therapy for the treatment of rotator cuff tears: a randomized controlled, crossover trial with 2-year follow-up

BackgroundSurgical repair is recommended for the treatment of high-grade partial and full thickness rotator cuff tears, although evidence shows surgery is not necessarily superior to non-surgical therapy. The purpose of this study was to compare percutaneous orthobiologic treatment to a home exercise therapy program for supraspinatus tears.MethodsIn this randomized-controlled, crossover design, participants with a torn supraspinatus tendon received either ‘BMC treatment’, consisting of a combination of autologous bone marrow concentrate (BMC) and platelet products, or underwent a home exercise therapy program. After three months, patients randomized to exercise therapy could crossover to receive BMC treatment if not satisfied with shoulder progression. Patient-reported outcomes of Numeric Pain Scale (NPS), Disabilities of the Arm, Shoulder, and Hand, (DASH), and a modified Single Assessment Numeric Evaluation (SANE) were collected at 1, 3, 6, 12, and 24 months. Pre- and post-treatment MRI were assessed using the Snyder Classification system.ResultsFifty-one patients were enrolled and randomized to the BMC treatment group (n = 34) or the exercise therapy group (n = 17). Significantly greater improvement in median ΔDASH, ΔNPS, and SANE scores were reported by the BMC treatment group compared to the exercise therapy group (-11.7 vs -3.8, P = 0.01; -2.0 vs 0.5, P = 0.004; and 50.0 vs 0.0, P < 0.001; respectively) after three months. Patient-reported outcomes continued to progress through the study’s two-year follow-up period without a serious adverse event. Of patients with both pre- and post-treatment MRIs, a majority (73%) showed evidence of healing post-BMC treatment.ConclusionsPatients reported significantly greater changes in function, pain, and overall improvement following BMC treatment compared to exercise therapy for high grade partial and full thickness supraspinatus tears.Trial registrationThis protocol was registered with www.clinicaltrials.gov (NCT01788683; 11/02/2013).

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

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

Denervation Procedure of the Lateral Epicondyle for Refractory Lateral Epicondylitis

BackgroundLateral epicondylitis is the most common cause of lateral elbow pain in adults, and non-operative treatment is the first-line management modality of choice. Pain refractory to conservative management may improve with surgical interventions involving ECRB débridement or denervation. This investigation was conducted to evaluate the long-term analgesic efficacy, incidence of postoperative sensory deficits, and postoperative elbow functionality in patients who underwent a denervation surgery of the posterior branch of the posterior cutaneous nerve of the forearm (PBPCNF) for refractory lateral epicondylitis. MethodsThis investigation was an IRB-approved, single-center, single-surgeon case series of 22 patients who underwent denervation surgery with an average final follow-up of 4.7 years. Inclusion criteria for surgery were a minimum of 6 months symptom duration refractory to conservative therapies, a minimum of 2 years clinical follow-up, and significant (70-80%) pain relief from the nerve block test. Visual Analog Scale (VAS) pain and Single Assessment Numerical Evaluation (SANE) scores were used to assess pain and function, respectively. The incidence of postoperative sensory deficits was evaluated via clinical exam. ResultsCompared to the preoperative average, the cohort’s mean VAS pain was significantly decreased at all postoperative follow-up intervals, including 2 weeks, 1 year, and final average follow-up of 4.7 years. At the final follow-up, the mean SANE score was 98.8 ± 2.6, and one patient (4.5%), who reported the same sensory deficit preoperatively, reported postoperative sensory deficits. ConclusionsThe PBPCNF denervation procedure is a highly efficacious procedure for achieving long-term pain control in the treatment of refractory lateral epicondylitis. The PBPCNF denervation procedure affords patients a high level of postoperative functionality with a low incidence of sensory deficits.

Incidence and risk factors for shoulder stiffness after open and arthroscopic rotator cuff repair.

The aim of this study was to estimate the incidence of stiffness during the first 6 months after rotator cuff repair and to evaluate postoperative stiffness with respect to its risk factors and its influence on the outcome at 6 months postoperatively. In a prospective cohort of 117 patients (69 women, 48 men; average age 59) from our institutional rotator cuff registry, who underwent either arthroscopic (n = 77) or open (n = 40) rotator cuff repair, we measured shoulder range of motion (ROM) at 3 and 6 months post-surgery. We evaluated the incidence of stiffness and analyzed functional outcomes, comparing various preoperative and intraoperative factors in patients with stiffness to those without at the 6-month mark. Shoulder stiffness was observed in 31% of patients (36/117) at 3 months postoperatively, decreasing to 20% (23/117) at 6 months. No significant link was found between stiffness at 6 months and demographic factors, preoperative stiffness, tear characteristics, or the type of repair. Notably, patients undergoing arthroscopic repair exhibited a 4.3-fold higher risk (OR 4.3; 95% CI 1.2-15.6, p = 0.02) of developing stiffness at 6 months compared to those with mini-open repair. Despite these differences in stiffness rates, no significant variation was seen in the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, or Visual Analog Scale (VAS) scores at 6 months between the groups. The incidence of postoperative shoulder stiffness following rotator cuff repair was substantial at 31% at 3 months, reducing to 20% by 6 months. Mini-open repair was associated with a lower 6-month stiffness incidence than arthroscopic repair, likely due to variations in rehabilitation protocols. However, the presence of stiffness at 6 months post-surgery did not significantly affect functional outcomes or pain levels.

Return to Sports Rates in Pediatric Patients After Bilateral Versus Unilateral Medial Patellofemoral Ligament Reconstruction

Background: Patellofemoral instability commonly occurs during sports activities. The return to sports (RTS) rate for pediatric patients after bilateral medial patellofemoral ligament reconstruction (MPFLR) is unknown. Purpose/Hypothesis: The purpose of this study was to evaluate RTS outcomes for pediatric patients undergoing bilateral MPFLR. It was hypothesized that (1) fewer pediatric patients would RTS after bilateral MPFLR compared with unilateral MPFLR and that (2) for those in the bilateral cohort who were able to RTS, fewer patients would attain the same level of play as or higher level than the preinjury level. Study Design: Cohort study; Level of evidence, 3. Methods: We prospectively collected RTS data on retrospectively identified matched cohorts of patients aged ≤18 years who underwent unilateral and bilateral MPFLR. We matched each participant with bilateral MPFLR at a 1 to 2 ratio with a participant with unilateral MPFLR by concomitant procedure, age, and sex. Postoperative complications and preoperative imaging measurements were collected from medical records. Patient-reported outcomes were obtained using a current Single Assessment Numeric Evaluation score collected at the time of primary outcome data. Results: We matched 16 participants (mean age, 14 years) who underwent bilateral MPFLR to 32 participants (mean age, 14.3 years) in a corresponding unilateral MPFLR cohort. We found a significant decrease in RTS rates for pediatric patients after bilateral MPFLR when compared with unilateral MPFLR (69% vs 94%; P = .03). Among those who returned to sports, there was no difference in the level of play achieved. For participants who did not RTS or returned at a lower level of play after bilateral MPFLR, 57% cited fear of reinjury as the primary reason. There were no differences in postoperative complications or current Single Assessment Numeric Evaluation scores between cohorts. The bilateral cohort had a significantly higher Caton-Deschamps index compared with the unilateral cohort, although the absolute difference was small (1.3 vs 1.2; P = .005). Conclusion: We found that pediatric patients have a lower RTS rate after bilateral MPFLR when compared with a matched unilateral MPFLR cohort. No differences in the level of play were achieved among those who returned to sports. Fear of reinjury was a commonly cited reason for not returning to sports.

Patellofemoral stabilization with and without cartilage restoration

PurposeCartilage restoration as an adjunct to patellofemoral (PF) soft tissue and/or bony stabilization in patients with symptomatic PF instability remains controversial. Our purpose was to evaluate patients undergoing surgical stabilization for PF instability with or without concomitant cartilage restoration. MethodsRetrospective review of prospectively collected data identified patients undergoing surgical stabilization for recurrent patella instability, with or without concomitant cartilage restoration. Presurgical and postsurgical patient-reported outcomes were collected. Complications requiring reoperation were recorded. Statistically significant difference was set at P < .05. ResultsOne hundred thirty patients (144 knees) were included. One hundred thirteen knees in the isolated stabilization (STAB) and 31 knees in the Stabilization-Cartilage Restoration (STAB-CART) group. The average age was 20.64 and 25.03 in the STAB and STAB-CART groups (P = .034), respectively. STAB-CART group had significantly lower preoperative Knee injury and Osteoarthritis Outcomes Score (57.24 ± 17.45 vs 46.11 ± 14.74, P = .019) and Single Assessment Numeric Evaluation scores (43.15 ± 19.05 vs 26.85 ± 13.74, P = .002). Both groups statistically improved in all Knee injury and Osteoarthritis Outcomes Score, International Knee Documentation Committee, and Single Assessment Numeric Evaluation domains with no statistically significant differences at final follow-up between groups. Thirteen knees (11.5%) in the STAB and 6 knees (19.4%) in the STAB-CART group had complications requiring reoperation, including 6 and 3 revision stabilizations, respectively. There were no statistically significant differences in total major complications (P = .246) or medial PF ligament revision (P = .405). ConclusionsThe addition of cartilage restoration in patients undergoing soft tissue and/or bony PF stabilization appears to be safe and effective. Despite lower baseline scores, patients undergoing PF stabilization with cartilage restoration had similar final subjective outcome scores compared to the group without.

Bridge Plating is an Effective Adjunct Treatment for Complex Elbow Instability

Managing persistent elbow instability and chronic dislocations presents challenges despite traditional treatments. Supplementary methods like immobilization and various fixations, though common, can carry high complication rates. This study assesses the efficacy of bridge plating in treating complex elbow instability through a retrospective review of patients. Data on characteristics, treatment duration, range of motion, complications, and evaluation scores were analyzed, providing insights into outcomes complications associated with bridge plating. Eleven patients were reviewed at an average follow-up of 80 ± 68 weeks. postoperatively. The average age was 53±14 years and there were 5 females and 6 males. The average BMI was 38. Bridge plating was used for a spectrum of complex elbow injuries. The average time from injury to bridge plating in acute cases was 29±19 days and 344±381 days in chronic cases. The average duration of bridge plating was 121 ± 72 days. At the time of plate removal, mean intraoperative elbow motion was extension 58±12°, flexion 107±14°, supination 66±23° and pronation 60±26°. At the latest follow-up visit, average elbow motion was extension 37±22°, Flexion 127± 17°, supination 72±15° and pronation 63±18°. There were 6 complications (55%); heterotopic ossification, ulnar neuropathy, wound failure over the plate in a thin patient, an ulnar shaft peri-prosthetic fracture due to a seizure induced fall, and elbow subluxation despite bridge plate fixation. One patient sustained a fracture of a 3.5mm locking bridge plate. One patient required a contracture release for persistent stiffness. Four of these complications can be directly attributed to the use of the bridge plate (36%). At final follow-up, the average patient rated elbow evaluation score was 34, with 0 indicating no pain and disability. The average single assessment numeric evaluation score was 66% for the 8 patients who had this available, with 100% being the best possible attainable score. Bridge plating effectively maintains joint reduction in selected complex elbow instability cases. However, patients with bridge plates often require a second surgery for removal and experience high rates of general complications due to the complexity of their condition.

Minimal Important Clinical Difference Values Are Not Uniformly Valid in the Active Duty Military Population Recovering from Shoulder Surgery

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of two different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operator curve (ROC) -based MCIDs and baseline-adjusted ROC MCIDs. All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROMs battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons score (ASES), Patient Reported Outcome Management Information System (PROMIS) Physical Function (PF), PROMIS Pain Interference (PI), and the Warfighter Readiness survey. Standard anchor-based and baseline-adjusted ROC MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval either completely negative or positive). There were 117 patients (136 operations) identified, comprised of 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7. When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC method was more effective at discerning changes across a battery of PROMs among the same cohort.

Clinical and Radiographic Outcomes of Shoulder Hemiarthroplasty for Patients with Glenoid Medialization

Glenoid bone loss in shoulder arthroplasty is a difficult problem that is prone to complications due to challenges with achieving glenoid component fixation and stability. The purpose of this study was to evaluate the outcomes of primary shoulder hemiarthroplasty for patients with severe glenoid medialization precluding placement of a glenoid component. This was a retrospective case series evaluating patients who underwent shoulder hemiarthroplasty for severe glenoid erosion and medialization between 2010 and 2020. Patients were evaluated via chart review and phone survey to determine if there were any reoperations at final follow-up and to obtain Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) scores. Preoperative and postoperative radiographs were evaluated and compared to determine glenoid morphology, version, medialization, acromiohumeral distance, and humeral offset. Final postoperative films were also evaluated for anterosuperior migration and signs of mechanical failure including loosening or periprosthetic fracture. Overall, there were 28 patients during this period who underwent shoulder hemiarthroplasty for severe glenoid medialization. Eight patients were deceased at the time of the study, 2 were unable to complete surveys due to dementia, and 7 were lost to follow-up. The final cohort included 11 shoulders and 11 patients with mean age of 71 +/- 7.1 years and mean follow-up of 6.7 years (range 1.6 - 13.0 years). Mean postoperative SANE, ASES, and SST scores were 80.6 +/- 17.6, 71.5 +/- 29.3, and 7.6 +/- 2.0, respectively. There were no reoperations or revision surgeries at final follow-up. Radiographic evaluation demonstrated severe glenoid medialization and decreased lateral humeral offset which was unchanged postoperatively. There were 2 patients with signs of anterosuperior migration at final radiographic follow-up but no signs of implant failure. Shoulder hemiarthroplasty for severe medial glenoid bone loss provides modest clinical outcomes and low rates of reoperation at mid to long term follow-up and is an option worth considering in cases where placement of a glenoid component is challenging due to deficient bone stock and high risk for complications.

Patients with chronic kidney disease can expect significant improvement in pain and function after shoulder arthroplasty

IntroductionChronic kidney disease (CKD) is associated with negative outcomes after hip and knee arthroplasty due to higher rates of infection, aseptic loosening, and transfusion. The purpose of this study was to compare clinical outcome scores and complication rate after shoulder arthroplasty for patients with and without CKD. MethodsWe conducted a retrospective cohort study of prospectively collected data and reviewed all patients who underwent primary shoulder arthroplasty from January 2015 to December 2019 by one surgeon at one institution. Revision arthroplasty patients were excluded. We evaluated results from patients with CKD (glomerular filtration rate [GFR] ≤ 59) and without CKD (GFR ≥ 60). Outcome measures including visual analog scale for pain, American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores were compared between cohorts. Minimal clinically important difference (MCID) and substantial clinical benefit also were determined for this cohort. Univariate and multivariable regression was performed to assess the influence of CKD on outcome measures and risk of complications. Results518 patients met inclusion criteria; 4 patients did not have recorded GFR, leaving 514 patients for analysis. 389 patients had normal GFR; 125 had CKD. Patients with CKD had lower overall preoperative and postoperative ASES, SST, and SANE scores but demonstrated similar levels of clinical improvement from preoperative to postoperative time points (Δ ASES 41.4 ± 21.8 vs. 42.9 ± 21.4, P = .55), (Δ SST 4.8 ± 3.4 vs. 4.9 ± 3.3, P = .08), (Δ SANE 40.7 ± 29.1 vs. 42.4 ± 26.5, P = .77). Both cohorts achieved MCID for ASES, SST, and SANE scores. Univariately, patients with CKD were at high risk to require transfusion (OR 16.2 (1.9, 139.7), P = .01) despite similar intraoperative estimated blood loss (156.9 ± 132.5mL vs. 153.8 ± 89.7mL, P = .77). CKD patients also were at higher risk for intraoperative fracture (OR 5.4 (1.3, 23.0), P = .02). CKD patients were not at higher risk for prosthetic joint infection (OR 3.2 (0.2, 50.8), P = .42), medical complications (OR 0.9 (0.2, 4.4), P = .89), or revision (OR 1.9 (0.7, 4.9), P = .19) in this cohort. Multivariable analysis of any complication after shoulder arthroplasty demonstrated that renal disease was not an independent risk factor for overall complication risk in this cohort (OR 1.1 (0.7, 1.8) P = .650). ConclusionSurgeons can be assured that patients who have CKD achieve similar gains in clinical outcomes as other patients. Despite experiencing a higher risk for transfusion and intraoperative fracture, renal disease was not an independent risk factor for complications after shoulder arthroplasty in this small cohort.

Anatomic shoulder arthroplasty in patients 40 years or younger

BackgroundGlenohumeral arthritis in adults less than 40 years old represents a challenging clinical scenario to manage. While patients older than 55 have had reproducible success with current shoulder arthroplasty techniques, young patients have historically had less successful outcomes, possibly due to higher physical demands and more complex pathologies. Despite these concerns, anatomic total shoulder arthroplasty (TSA) remains the treatment of choice for young, active patients with severe glenohumeral arthritis and intact rotator cuff. We hypothesize that TSA provides significant relief in pain and functional outcomes in patients less than 40 years old. MethodsWe performed a single-institution retrospective analysis of consecutive patients aged 40 years and younger who underwent TSA between 2007 and 2022. Demographic data included age, sex, body mass index, Charlson comorbidity index, and preoperative diagnosis. Outcome measures included the Single-Assessment Numerical Evaluation (SANE) score, final range of motion, complications, and revision rate. Statistically significant differences between variables were evaluated using a 2-sample t-test at an α level of P < .05. ResultsTwenty-six TSAs were performed in 23 patients with an average final follow-up of 2 years after the procedure. The average age was 33.4 ± 5.3 years with a range of 19-39 years. The most common preoperative diagnosis was osteoarthritis (46%), followed by rheumatoid arthritis (27%) and osteonecrosis/avascular necrosis (19%). The most common glenoid morphology was type B (15) of which 14 were B2 glenoid, followed by type A (11). The SANE score, mean active forward elevation, abduction, external rotation, and internal rotation all improved significantly (P < .05) by the final follow-up. On average, patients in all groups were able to achieve minimal clinically important difference in SANE score after 1 year. There was 1 complication reported of an early postoperative infection treated with irrigation and débridement, and no revision surgeries were performed during the follow-up period. Discussion/ConclusionTSA significantly improved functional outcome measures in patients less than 40 years old with a low rate of complications and revisions in short-term outcomes. As the frequency of TSA continues to increase in adults less than 40 years old, additional studies recording long-term functional outcomes and implant survivorship in this population can be explored.

Clinical Outcomes of Arthroscopic Superior Capsular Reconstruction Using Fascia Lata Autograft Versus Reverse Shoulder Arthroplasty in Patients 65 Years and Older With Irreparable Rotator Cuff Tears: A Retrospective Cohort Study.

Arthroscopic superior capsular reconstruction (ASCR) and reverse shoulder arthroplasty (RSA) have both shown favorable outcomes in patients with irreparable rotator cuff tears (IRCTs). To (1) compare the clinical outcomes of ASCR versus RSA in patients aged ≥65 years with IRCTs and (2) compare serial changes in clinical outcomes between treatment groups. Cohort study; Level of evidence, 3. This study included patients with IRCTs without glenohumeral osteoarthritis who underwent either ASCR or RSA between March 2013 and December 2020 and had at least 2 years of follow-up data. We assessed active range of motion, a visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, and the Single Assessment Numeric Evaluation (SANE) score at the preoperative, short-term (postoperative 6-12 months), and final follow-up times. In total, 64 patients (ASCR, 31 patients; RSA, 33 patients) were included. The mean age of patients was 71.3 ± 4.4 and 72.9 ± 4.1 years, and the mean final follow-up duration was 42 ± 21.8 and 37.7 ± 21.7 months in the ASCR and RSA groups, respectively. At the short-term follow-up, RSA achieved significant improvements in all clinical outcomes, except for internal rotation (IR), while ASCR only showed significant improvements in VAS pain, ASES, and SANE scores. Compared with the preoperative period, both ASCR and RSA achieved significant improvements in all clinical outcomes, except for IR in the RSA group at the final follow-up. The ASCR group achieved better IR and ASES scores at the final follow-up, while the time taken to recover from pseudoparalysis was shorter after RSA. The ASCR group showed a 67.8% graft healing rate at the 1-year follow-up, while the RSA group showed 12.1% of scapular notching at the final follow-up. No other postoperative complications were observed in either group. ASCR and RSA achieved favorable clinical outcomes in the study cohort. At the short-term follow-up, RSA showed significant improvements in all clinical outcomes, except for IR, while ASCR only showed significant improvements in VAS pain, ASES, and SANE scores. At the final follow-up, however, ASCR had better IR and ASES scores compared with RSA.

Addition of Preoperative Ultrasound-Guided Suprascapular Nerve Block and Axillary Nerve Block to Parecoxib Is More Effective in Early Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Study

PurposeThe purpose of the study was to prospectively compare the pain intensity and patient-reported outcomes (PROs) following arthroscopic rotator cuff repair (ARCR) between patients who received ultrasound-guided suprascapular nerve block (SSNB) and axillary nerve block (ANB) as well as preincisional parecoxib and patients who received preincisional parecoxib only. MethodsSixty-one patients receiving ARCR between March 2020 and March 2021 were prospectively enrolled. They were randomly assigned to the peripheral nerve block group (group N, n=30) or control group (group C, n=31). Two patients from group C were excluded because of miscommunication. All patients were administered parecoxib 40 mg intravenously prior to induction of anesthesia. In group N, SSNB/ANB were performed after general anesthesia while no nerve block was performed in group C. The pain intensity was compared before the surgery, as well as immediately, 24 hours and 2 weeks after the surgery. PROs, including Oxford shoulder score, University of California-Los Angeles shoulder score and Single Assessment Numeric Evaluation score, were compared before and 6 months after the surgery. ResultsThe resting pain numerical rating scale (NRS) was significantly lower in group N (4.9 ± 3.1 vs. 7.6 ± 2.5, p<0.001) immediately after the surgery, but no difference was noted 24 hours after the surgery. The resting pain NRS 2 weeks after the surgery was significantly lower in group N (1.4 ± 1.6 vs. 2.7 ± 2.7, p=0.03), but the movement-evoked pain and night pain were similar. All PROs significantly improved 6 months after the surgery in both groups, but there was no difference between the 2 groups. ConclusionAddition of preoperative ultrasound-guided SSNB and ANB to parecoxib offered better resting pain control immediately and 2 weeks after ARCR, but there was no benefit for PROs 6 months after the surgery. Level of EvidenceLevel 2 prospective randomized controlled trial

Operative Treatment of Ulnar Collateral Ligament Injury in Female Athletes.

Ulnar collateral ligament (UCL) reconstruction has been the standard surgical intervention for elite male athletes with UCL insufficiency. Recently, UCL repair and augmentation with an internal brace has been increasingly performed. To evaluate the clinical and functional outcomes as well as return-to-sport rate after UCL repair in female athletes. Case series; Level of evidence, 4. Included were 15 female athletes (mean age, 16.5 ± 3.5 years) who underwent UCL repair between 2011 and 2021 at a single institution. Data collected included age, sport played, competition level, symptom onset, previous surgeries, mechanism of injury, surgical intervention, and return to sport. Patients were contacted via phone at minimum 24-month follow-up, and postoperative outcomes were evaluated using the Mayo Elbow Performance Score (MEPS) and the Single Assessment Numeric Evaluation (SANE). Of the 15 female athletes, there were 4 cheerleaders, 3 softball players, 2 volleyball players, 2 soccer players, 1 gymnast, 1 tennis player, 1 dancer, and 1 javelin thrower. Ten of the 15 athletes (67%) competed at the high school level, 4 (26%) at the collegiate level, and 1 patient (7%) was a recreational volleyball player. In all patients, there was an acute onset of symptoms after injury. Ten patients underwent UCL repair with an internal brace (67% of athletes), while 5 underwent standard UCL repair. The median MEPS for athletes with and without an internal brace was 100 (range, 80-100). There was no significant difference of MEPS (P = .826) or SANE scores (P = .189) between the patients who received an internal brace and those who did not. Thirteen of the 15 athletes (86.7%) returned to sport. The UCL injuries in the female athletes in this study were the result of acute trauma. Primary UCL repair, both with and without internal bracing, was an effective surgical treatment for returning these athletes to sport.

Arthroscopic Fractional Lengthening After Total Hip Arthroplasty Results in Improved Patient-Reported Outcomes and Low Rates of Revision Total Hip Arthroplasty

PurposeTo report the clinical outcomes and reoperation rates of arthro- and endo-scopic iliopsoas release at short-term follow-up following ipsilateral total hip arthroplasty from two separate medical institutions, and to evaluate whether demographic and radiographic parameters are associated with postoperative patient reported outcomes. MethodsPatients with iliopsoas tendinitis in the setting of prior THA that underwent arthroscopic iliopsoas fractional lengthening from 1988 – 2023 at two academic institutions were reviewed. Patients were included if they had 12 months of follow-up and evaluated for preoperative anterior acetabular component overhang, surgery satisfaction, postoperative subjective hip flexion strength and anterior groin pain improvement, modified Harris Hip Score (mHHS), Single Assessment Numeric Evaluation (SANE) score, Tegner activity scale, visual analog scale (VAS), and revision hip arthroplasty. ResultsSixty hips in 58 patients (19 males, 39 females) were followed for a mean of 39.3 (12.0-105.9) months postoperatively. 77% of patients reported feeling “much” or “slightly better”, 75% reported improved anterior groin pain, and 60% reported improved subjective hip flexion strength. Surgery satisfaction was 7.2 ± 3.3 (scale of 0 to 10). Mean postoperative mHHS, VAS pain at rest, VAS pain with use, and SANE scores were 73.9 ± 19.4, 1.3 ± 2.4, 3.8 ± 2.9, and 71.9 ± 21.9 respectively. Preoperative anterior acetabular component overhang was 3.3 ± 6.5 mm and didn’t significantly correlate with postoperative PROs (p ≥ 0.45). Tegner score improved to 2.9 ± 1.4 from 2.5 ± 1.7 preoperatively (p = 0.0253). Three patients underwent revision arthroplasty at a mean of 25.3 (11.6 – 40.4) months postoperatively, with an acetabular component revision rate of 3.3%. ConclusionsSatisfactory outcomes and low revision arthroplasty rates were observed in patients undergoing arthroscopic iliopsoas lengthening following THA. There was no statistically significant relationship between anterior acetabular component overhang and final PROs.

Structural bone grafting for glenoid bone loss in primary anatomic total shoulder arthroplasty: a case series and technique report

IntroductionPosterior glenoid bone loss in glenohumeral osteoarthritis poses significant challenges in shoulder arthroplasty. Anatomic total shoulder arthroplasty with a humeral head autograft to address the glenoid bone deficiency is an option for these difficult cases. Variable results with this procedure are reported in the literature. This article describes the surgical technique of posterior glenoid bone grafting in TSA using a glenoid implant with hybrid fixation, and a series of reported patient functional and radiographic outcomes. Materials and MethodsA retrospective chart review of cases from 2015 to 2020 by a single surgeon revealed 10 patients who underwent primary TSA with hybrid glenoid component and posterior glenoid bone grafting. Preoperative and postoperative radiographs were assessed for glenoid inclination, glenoid version, acromiohumeral distance, humeral stem status, and glenoid implant status. Functional outcomes were evaluated by range of motion, strength, and patient-reported clinical outcomes (pain and function on a visual analog scale, disabilities of the arm, shoulder, and hand score, single assessment numeric evaluation, American Shoulder and Elbow Surgeons score). Complications and reoperations were also evaluated. ResultsAverage follow-up was 31.4 months, active forward flexion and external rotation improved on average from 105o to 150o and 20o to 60o, respectively (P<0.001) and average abduction improved from 100o to 140o (P<0.002). At an average of 26.7 months, patients reported assessments (VAS pain and function, QuickDASH, SANE, ASES scores) reveal significant (P<0.05) improvement in pain and functional outcomes. Radiographically, at 23.0 ± 20.1 months, all patients demonstrated a well fixed humeral and glenoid component without evidence of lucent lines. The bone graft used in each patient was well unionized and no radiographic complications were reported. No patients underwent revision surgery, and there was one clinical complication reported, which consisted of a suspected rotator cuff injury at follow-up. ConclusionHybrid fixation with structural glenoid bone grafting in TSA resulted in excellent outcomes with no evidence of graft or component failure on follow-up radiographs and significantly reduced pain, improved functional scores, and improved active ROM.

Outcomes of Concomitant Glenohumeral Stabilization After Arthroscopic Rotator Cuff Repair in Military Patients Younger Than 40 Years.

While concomitant rotator cuff and inferior labral tears are relatively uncommon in young civilians, military populations represent a unique opportunity to study this injury pattern. To (1) evaluate the long-term outcomes after combined arthroscopic rotator cuff and inferior labral repair in military patients <40 years and (2) compare functional outcomes with those after isolated arthroscopic rotator cuff repair. Cohort study; Level of evidence, 3. Military patients who underwent arthroscopic rotator cuff repair between January 2011 and December 2016 and had a minimum of 5-year follow-up data were included in this study. The patients were categorized into those who had undergone combined arthroscopic rotator cuff and inferior labral repair (RCIL cohort) and those who had isolated arthroscopic rotator cuff repair (ARCR cohort). Pre- and postoperative outcome measures-visual analog scale for pain, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, Rowe Instability Score, and range of motion-were compared between the groups. A total of 50 shoulders (27 in the RCIL cohort and 23 in the ARCR cohort) were assessed. The RCIL and ARCR groups were similar in terms of age (mean, 33.19 years [range, 21-39 years] vs 35.39 years [range, 26-39 years], respectively) and sex (% male, 88.46% vs 82.61%, respectively). All patients were active-duty military at the time of surgery. The mean final follow-up was at 106.93 ± 16.66 months for the RCIL group and 105.70 ± 7.52 months for the ARCR group (P = .75). There were no differences in preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all), and there were no significant group differences in any final postoperative outcome measures. At the final follow-up, 26 (96.30%) patients in the RCIL cohort and 20 (86.96%) in the ARCR cohort had returned to unrestricted active-duty military service (P = .3223). The study findings indicate that concomitant glenohumeral stabilization does not prevent worse outcomes after arthroscopic rotator cuff repair in this military cohort. Combined repair produced statistically and clinically significant improvements in outcome scores at the long-term follow-up, indicating that simultaneous repair of combined lesions was an appropriate treatment option in this patient population.

Intermediate Outcomes of Medial Ulnar Collateral Ligament Reconstruction Using Gracilis Allograft in Adolescent Patients.

Autograft palmaris has been the primary choice for the reconstruction of the medial ulnar collateral ligament (UCL) in the elbow. Agenesis of the palmaris tendon is not rare, and outcomes of allograft reconstruction in the breadth of athlete types found in the adolescent population are lacking. Allograft tendon reconstruction of the medial UCL in the young elbow would have low failure rates and satisfactory outcome scores. Case series; Level of evidence, 4. The records of patients who underwent allograft medial UCL reconstruction (UCLR) by a single surgeon between 2009 and 2019 were reviewed. Patient-reported outcome scores in adolescent patients obtained at a minimum 4-year follow-up (for intermediate assessment) were recorded, with no exclusion according to sex or sport type. Outcomes included the Timmerman-Andrews score, the Single Assessment Numeric Evaluation (SANE), and the Conway-Jobe score. Of 29 patients who underwent allograft UCLR, 10 adolescents (40% women; mean age at surgery, 15.8 years [age range, 15-17 years]) met the inclusion criteria and were included in the study. The mean follow-up was 8 years (range, 4.3-11.9 years). There were 4 overhead athletes (baseball, water polo) and 6 impact sports athletes (motocross, gymnastics, wrestling, and soccer). The mean SANE score was 86.3, and the mean subjective Timmerman-Andrews score was 92.5. The Conway-Jobe score was "excellent" in 7 of 10 participants; nonetheless, 3 elected not to return to sport (2 for reasons unrelated to the elbow). No patients experienced loss of range of motion, contracture, or ulnar nerve neuropathy. There was 1 patient with early failure (10%) who required revision reconstruction . Allograft reconstruction for medial UCL instability in adolescent patients from sport and trauma mechanisms demonstrated excellent patient-reported functional scores in this study. If the patient and surgeon desire to avoid autograft morbidity or agenesis of the palmaris longus, allograft tendon UCLR appears viable for both the throwing and the high-impact adolescent athlete, regardless of sex.

Combined, Single-Anchor Subscapularis Tendon Repair and Proximal Biceps Tenodesis Leads to Improved Function and Decreased Pain at 1 Year

PurposeThe purpose of this study was to evaluate the 1-year clinical outcomes of patients treated with combined proximal biceps tenodesis and repair of type II-III subscapularis tendon injuries according to Lafosse et al, using the Loop ‘N’ Tack (LNT) technique. MethodsAll patients undergoing proximal biceps tenodesis and rotator cuff repair (RCR) between March 1st, 2020 and January 30th, 2022 were retrospectively identified. Only patients undergoing combined proximal biceps tenodesis and repair of grade II or III SST injuries with a minimum follow-up of 1 year were included. All patients underwent combined single anchor proximal biceps tenodesis and SST repair using the Loop ‘N’ Tack (LNT) technique. The following outcome scores were recorded at a final follow-up of 1-year postoperatively and were compared to baseline, preoperative values: American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), Veterans Rand 12 Item Health Survey (VR-12), and Visual Analog Score (VAS). The minimal clinically important difference (MCID) for all outcome indices was determined with a distribution-based method. ResultsA total of 41 consecutive patients were included. The MCID value for VAS pain, ASES, SANE, and VR-12 mental scores were 0.97, 8.5, 10.9, and 6.0 respectively. At 1-year final follow-up, approximately 95% (39/41) of patients exceeded the MCID for VAS pain scores, 90% (37/41) of patients for ASES scores, 85.4% (34/41) of patients for SANE scores, and 75.6% (31/41) of patients for VR-12 mental health scores. On average, ASES and SANE scores improved by 37 (Pre: 45.2, 1yr: 82.4, p<0.001) and 38 points (Pre: 38.0, 1yr: 75.7, p<0.001) respectively while VAS scores decreased by 4 points (Pre: 5.49, 1yr: 1.48, p<0.001). Approximately 88% (36/41) of patients were satisfied at 1 year post-operatively. Treatment failure was observed in one patient (2.4%). ConclusionPatients treated with combined, single-anchor SST repair and LNT proximal biceps tenodesis achieved significant improvements in function, high satisfaction, and low rates of re-operation at 1 year postoperatively. Additionally, 76% to 95% of patients met the MCID for VAS pain, ASES, SANE, and VR-12 mental health scores. Level of EvidenceLevel IV, retrospective case series