Can we accelerate rehabilitation following reverse shoulder arthroplasty? A systematic review.

Background: There is no consensus concerning the rehabilitation protocol following reverse shoulder arthroplasty. Several patients are expecting to be able to use their arms for sports or recreation shortly after their operation. Methods: This review was designed as an intervention systematic review with narrative analysis. Authors searched English literature in PubMed and Embase databases from 1/1/1989 until July 2022. Controlled studies comparing rehabilitation protocols for patients undergoing reverse shoulder arthroplasty were included. Data quality was examined with the Cochrane risk of a bias assessment tool for randomized trials, the Methodological Index for Non-Randomized studies (MINORS) tool, as well as the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach. Results: Three studies were finally analyzed. At 3 months post-op, forward flexion was found to be significantly higher in the early rehabilitation group (140.5, 95% confidence intervals (CIs): 135.10-145.89; the delayed rehabilitation group mean was 131.24, 95% CI: 125.73-136.74; p = 0.019). Twelve months post-op, no significant difference in any clinical or patient-reported outcome was shown. More complications were reported in the 6 weeks-delayed rehabilitation group. Discussion: Newer regimes permit immediate shoulder mobilization but may not be applied to every patient. The lack of strong evidence warrants the need for future controlled studies; subsequently, postoperative rehabilitation should be individualized.

Bracing with Tape and Extensor Refixation of Elbow with Posterolateral Instability Due to Cubitus Varus: A Case Report.

CASE: A 54-year-old patient had lateral ligament insufficiency due to cubitus varus from a childhood supracondylar fracture. Arthrolysis/synovectomy and at a later stage double-row extensor origin refixation and lateral ulnar collateral ligament bracing with nonabsorbent tape and anchors were performed. Follow-up at 3, 6, 12, and 24 months showed excellent Mayo Elbow Performance and Disabilities of Arm, Shoulder, and Hand Scores (24-month follow-up = 100 and 2.5, respectively). CONCLUSION: Suture tape augmentation and double-row extensor refixation in cases of lateral collateral ligament complex insufficiency due to cubitus varus may provide improved short-term functional outcomes, from the third postoperative month.

Risk for Fracture with Acromioclavicular Joint Reconstruction and Strategies for Mitigation.

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, especially among athletes. Surgical reconstruction of the AC joint can lead to complications such as fracture of the coracoid process, clavicle or acromion, which can negatively affect the patient's outcome. The purpose of this review is to discuss the risk factors for fractures associated with AC joint reconstruction, as well as the strategies that can be used to mitigate this risk. Risk factors for fractures include low mineral density, coracoid/clavicle drilling, larger holes in the coracoid, and the number of tunnels used for reconstruction.

The importance of a structured failure analysis in revision acromioclavicular joint surgery: A multi-rater agreement on the causes of stabilization failure from the ISAKOS shoulder committee.

BACKGROUND: Acromioclavicular joint (ACJ) stabilizations are associated with a high overall failure rate with 9.5% of these patients requiring subsequent revision surgery. Consequently, understanding the specific cause of primary ACJ stabilization failure is paramount to improving surgical decision-making in this challenging patient cohort. PURPOSE: To (1) identify risk factors and mechanisms for failure following primary arthroscopically-assisted ACJ stabilization to highlight the importance of conducting a detailed failure analysis and to (2) establish revision strategies based on real-life cases of primary failed ACJ stabilization. STUDY DESIGN: Level of evidence IV. METHODS: A survey was shared internationally among members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) shoulder committee. The survey contained failure analysis of 11 real-life cases of failed primary arthroscopically-assisted ACJ stabilization. For each case, a thorough patient history, standardized radiographs, and CT scans were provided. Participants were asked to give their opinion on bone tunnel placement, cause of failure (biological, technical, traumatic, or combined), the stabilization technique used, as well as give a recommendation for revision. RESULTS: Seventeen members of the ISAKOS shoulder committee completed the survey. Biological failure was considered the most common cause of failure (47.1%), followed by technical (35.3%) and traumatic (17.6%) failure. The majority deemed two modifiable factors (i.e., patient's profession and sport) as well as non-modifiable factors (i.e., patient's age and time from trauma to initial surgery) to be risk factors for failure. In 10 of 11 cases, the correct fixation device was used in the primary setting (90.9%; 52.8-82.4% agreement); however, in eight of those cases, the technique was not performed correctly (80.0%; 58.8-100% agreement). In 8 of all 11 cases, the majority recommended an arthroscopically assisted technique with graft augmentation for revision (52.9-58.8% agreement). CONCLUSION: Biological failure and technical failure are the most common reason for failure in primary ACJ stabilization followed by traumatic failure. Besides, biological failure can be triggered by technical errors such as clavicular or coracoidal tunnel misplacement. Consequently, a detailed failure analysis including preoperative CT should be conducted on the causes of primary ACJ failure, and, if possible, an arthroscopically-assisted technique with graft augmentation should be prioritized in revision ACJ surgery. CLINICAL RELEVANCE: ACJ stabilizations are associated with a high overall failure rate - potentially due to biological and technical properties. When encountering failed arthroscopically-assisted ACJ stabilization, a detailed failure analysis should be conducted on the causes of primary ACJ failure. Furthermore, an arthroscopically-assisted revision stabilization is feasible in most cases.

Arthroscopic Modified Elbow Lateral Collateral Ligament Imbrication: An Operative Technique.

When the lateral collateral ligament (LCL) complex fails to support the radiocapitellar and ulnohumeral joints in advanced stages of insufficiency, the patient experiences posterolateral rotatory instability (PLRI). Open lateral ulnar collateral ligament repair with a ligamentous graft has been the standard treatment for PLRI. Despite producing good clinical stability rates, this method is associated with significant lateral soft-tissue dissection and a lengthy recovery period. By fastening the LCL to its humeral insertion, arthroscopic imbrication of the LCL can increase stability. The senior author modified this technique. With the aid of a passer, the LCL complex, lateral capsule, and anconeus may be weaved with a single (doubled) suture, secured with a Nice knot. LCL complex imbrication may be used to restore stability and improve pain and function in patients with grade I and II PLRI.

Intact revision rotator cuff repair stabilizes muscle atrophy and fatty infiltration after minimum follow up of two years.

BACKGROUND: The extent of fatty infiltration and rotator cuff (RC) atrophy is crucial for the clinical results after rotator cuff repair (RCR). The purpose of this study was to evaluate changes in fatty infiltration and RC atrophy after revision RCR and to correlate them with functional outcome parameters. METHODS: Patients who underwent arthroscopic revision RCR for symptomatic recurrent full-thickness tear of the supraspinatus tendon between 2008 and 2014 and were retrospectively reviewed with a minimum follow up of 2 years. Magnetic resonance imaging (MRI) was performed pre- and postoperatively to assess 1) tendon integrity after revision RCR according to Sugaya classification, (2) RC atrophy according to Thomazeau classification, and (3) fatty infiltration according to Fuchs MRI classification. Constant score (CS) and the American Shoulder and Elbow Surgeon (ASES) score were used to correlate functional outcome, tendon integrity, and muscle degeneration. RESULTS: 19 patients (17 males and 2 females) with a mean age of 57.5 years (range, 34 to 72) were included into the study at a mean follow-up of 50.3 months (range, 24 - 101). At final evaluation, 9 patients (47%) presented with intact RCR and 10 patients (53%) suffered a re-tear after revision repair. No progress of fatty infiltration was observed postoperatively in the group with intact RC, atrophy progressed in only 1 out of 9 patient (11%). Fatty infiltration progressed in 5/10 patients (50%) and RC atrophy increased in 2/10 patients (20%) within the re-tear group. CS (42.7 ± 17.7 preop, 65.2 ± 20.1 postop) and ASES (47.7 ± 17.2 preop, 75.4 ± 23.7 postop) improved significantly from pre- to postoperatively (p < 0.001). A positive correlation between fatty infiltration and RC integrity was detected (r = 0.77, p < 0.01). No correlation between clinical outcome and tendon integrity or RC atrophy was observed. CONCLUSION: Arthroscopic revision RCR leads to reliable functional outcomes even in case of a recurrent RC retear. An intact RCR maintains the preoperative state of fatty infiltration and muscle atrophy but does not lead to muscle regeneration. LEVEL OF EVIDENCE: Level IV; Therapeutic study.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads in a Dynamic Biomechanical Shoulder Model.

PURPOSE: To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement after superior capsular reconstruction (SCR) using an acellular dermal allograft. METHODS: Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, and (3) SCR using a 3-mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3-dimensional motion-tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including glenohumeral contact area and glenohumeral contact pressure (gCP), were assessed at rest, 15°, 30°, 45°, and maximum angle of glenohumeral abduction. RESULTS: The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P < .001, respectively). SCR did not restore native gAA (P < .001); however, SM was significantly reduced (P < .001). Further, SCR significantly reduced deltoid forces at 30° (P = .007) and 45° of abduction (P = .007) when compared with the PSRCT. SCR did not restore native cDF at 30° (P = .015), 45° (P < .001), and maximum angle (P < .001) of glenohumeral abduction. Compared with the PSRCT, SCR resulted in a significant decrease of gCP at 15° (P = .008), 30° (P = .002), and 45° (P = .006). However, SCR did not completely restore native gCP at 45° (P = .038) and maximum abduction angle (P = .014). CONCLUSIONS: In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared with the posterosuperior rotator cuff tear. CLINICAL RELEVANCE: These observations raise concerns regarding the true joint-preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Current concepts in acromioclavicular joint (AC) instability - a proposed treatment algorithm for acute and chronic AC-joint surgery.

BACKGROUND: There exists a vast number of surgical treatment options for acromioclavicular (AC) joint injuries, and the current literature has yet to determine an equivocally superior treatment. AC joint repair has a long history and dates back to the beginning of the twentieth century. MAIN BODY: Since then, over 150 different techniques have been described, covering open and closed techniques. Low grade injuries such as Type I-II according to the modified Rockwood classification should be treated conservatively, while high-grade injuries (types IV-VI) may be indicated for operative treatment. However, controversy exists if operative treatment is superior to nonoperative treatment, especially in grade III injuries, as functional impairment due to scapular dyskinesia or chronic pain remains concerning following non-operative treatment. Patients with a stable AC joint without overriding of the clavicle and without significant scapular dysfunction (Type IIIA) may benefit from non-interventional approaches, in contrast to patients with overriding of the clavicle and therapy-resistant scapular dysfunction (Type IIIB). If these patients are considered non-responders to a conservative approach, an anatomic AC joint reconstruction using a hybrid technique should be considered. In chronic AC joint injuries, surgery is indicated after failed nonoperative treatment of 3 to 6 months. Anatomic AC joint reconstruction techniques along with biologic augmentation (e.g. Hybrid techniques, suture fixation) should be considered for chronic high-grade instabilities, accounting for the lack of intrinsic healing and scar-forming potential of the ligamentous tissue in the chronic setting. However, complication and clinical failure rates remain high, which may be a result of technical failures or persistent horizontal and rotational instability. CONCLUSION: Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint.

Risk factors and prevention strategies for shoulder injuries in overhead sports: an updated systematic review.

PURPOSE: The aim of this systematic review was to update the knowledge on risk factors and prevention strategies for shoulder injuries in overhead sports with special emphasis on methodological quality. METHODS: All methodological procedures were performed in line with a previous systematic review by Asker et al. (2018). The literature search was conducted in the PubMed, Google Scholar, Cochrane, and SPORT-Discuss databases. Due to the risk of bias assessment, only studies with at least an acceptable methodological quality were included. A best-evidence synthesis was performed to clarify the evidence and direction of the risk factors and prevention strategies. RESULTS: A total of nine studies were included in the data extraction process. One study had a high and eight studies had an acceptable methodological quality. Seven cohort studies investigated risk factors and two randomised controlled trails evaluated prevention strategies. Moderate evidence was found for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) that were associated with the shoulder injury risk. All further risk factors had moderate and no association with risk (shoulder rotational ROM, joint position sense) or limited (history of shoulder/elbow pain, age, training experience, training volume, school grade, playing level), and conflicting evidence (setting). CONCLUSIONS: There is moderate evidence for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) being associated with the shoulder injury risk in overhead sports.

Biomechanical comparison of lower trapezius and latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears using a dynamic shoulder model.

BACKGROUND: In the setting of irreparable posterosuperior rotator cuff tears (PSRCTs), lower trapezius transfer (LTT) may be anatomically better positioned for restoring the muscular force couple compared with latissimus dorsi transfer (LDT). The purpose of the study was to evaluate the effect of LTT and LDT on glenohumeral kinematics using a dynamic shoulder model. METHODS: Ten fresh-frozen cadaveric shoulders (mean age: 56.5 ± 17.2 years) were tested using a dynamic shoulder simulator. The maximum abduction angle (MAA), superior humeral head migration (SHM), and cumulative deltoid forces (CDFs) were compared across 4 conditions: (1) native; (2) irreparable PSRCT; (3) LTT using an Achilles tendon allograft; and (4) LDT. MAA and SHM were measured using 3-dimensional motion tracking. CDF was recorded in real time throughout the dynamic abduction motion by load cells connected to actuators. RESULTS: Compared to the native state, the PSRCT resulted in a significant decrease (Δ-24.1°; P < .001) in MAA, with a subsequent significant increase after LTT (Δ13.1°; P < .001) and LDT (Δ8.9°; P < .001). LTT achieved a significantly greater MAA than LDT (Δ4.2°; P = .004). Regarding SHM, both LTT (Δ-9.4 mm; P < .001) and LDT (Δ-5.0 mm; P = .008) demonstrated a significant decrease compared with the PSRCT state. LTT also achieved significantly less SHM compared with the LDT (Δ-4.4 mm; P = .011). Further, only the LTT resulted in a significant decrease in CDF compared with the PSRCT state (Δ-21.3 N; P = .048), whereas LTT and LDT showed similar CDF (Δ-11.3 N; P = .346). However, no technique was able to restore the MAA, SHM, and CDF of the native shoulder (P < .001, respectively). CONCLUSION: LTT and LDT both achieved a significant increase in MAA along with significantly less SHM compared with the PSRCT state. Although LTT required significantly less compensatory deltoid forces compared with the PSRCT state, this was not observed for the LDT. Further, the LTT prevented loss of abduction motion and SHM more sufficiently. In the challenging treatment of irreparable PSRCTs, LTT may restore native glenohumeral kinematics more sufficiently, potentially leading to improved postoperative functional outcomes.

Rotational range of motion of elliptical and spherical heads in shoulder arthroplasty: a dynamic biomechanical evaluation.

INTRODUCTION: Elliptical shape humeral head prostheses have been proposed to reflect a more anatomic shoulder replacement. Its effect on the rotational range of motion (ROM) compared to a standard spherical head is still not understood. The purpose was to investigate if there would be a difference in rotational ROM when comparing elliptical and spherical prosthetic heads in a dynamic shoulder model. The authors hypothesized that the use of elliptical heads would result in significantly more rotational ROM compared to the spherical head design. MATERIALS AND METHODS: Six fresh-frozen, cadaveric shoulders were evaluated using a dynamic shoulder model. After being tested in the native condition, each specimen underwent 6 conditions in the hemiarthroplasty state: (1) matched-fit spherical head, (2) oversized spherical head, (3) undersized spherical head, (4) matched-fit elliptical head, (5) oversized elliptical head, and (6) undersized elliptical head. Following conversion to total shoulder arthroplasty (TSA), the 6 prior conditions were rerun. Each condition was tested at 0°, 30° and 60° of glenohumeral abduction. Rotational ROM was quantified using 3-dimensional tracking, while dynamically applying alternating forces for internal and external rotation via the rotator cuff tendons. RESULTS: Elliptical and spherical prosthetic heads showed no significant difference in the degree of the total, internal, and external rotational ROM for both the hemiarthroplasty and TSA state. Conversion from hemiarthroplasty to TSA resulted in less degree of total rotational ROM for both head designs in all abduction positions, without reaching statistical significance. There was a significant decrease in total, internal, and external rotational ROM for both elliptical and spherical heads in every replacement condition, when comparing 0° to 30° and 60° of abduction (P < 0.05, respectively). CONCLUSION: In a dynamic shoulder model, elliptical and spherical prosthetic head designs showed no significant difference in the degree of the total, internal, and external rotational ROM in both the hemiarthroplasty and TSA state. LEVEL OF EVIDENCE: Controlled laboratory study.

Center of pressure (COP) measurement in patients with confirmed successful outcomes following shoulder surgery show significant sensorimotor deficits.

PURPOSE: To determine the sensorimotor and clinical function of patients with confirmed successful outcome after either undergoing acromioclavicular joint (ACJ) stabilization, Bankart repair (BR), or rotator cuff repair (RC), and to compare these measures to the contralateral, healthy side without history of previous injuries or surgeries of the upper extremity. It was hypothesized that patients of each interventional group would have inferior sensorimotor function of the shoulder joint compared to the contralateral, healthy side, while presenting with successful clinical and functional outcomes. METHODS: Three intervention groups including ten patients who had confirmed successful clinical and functional outcomes after either undergoing ACJ stabilization, BR, or RC were evaluated postoperatively at an average follow-up of 31.7 ± 11.6 months. Additionally, a healthy control group (CG) of ten patients was included. Clinical outcomes were assessed using the Constant-Murley (CM) and American Shoulder and Elbow Surgeons (ASES) Score. Pain was evaluated using the visual analogue scale (VAS). Sensorimotor function was assessed by determining the center of pressure (COP) of the shoulder joint in a one-handed support task in supine position on a validated pressure plate. RESULTS: Each interventional group demonstrated excellent clinical outcome scores including the CM Score (ACJ 83.3 ± 11.8; BR 89.0 ± 10.3; RC 81.4 ± 8.8), ASES Score (ACJ 95.5 ± 7.0; BR 92.5 ± 9.6; RC 96.5 ± 5.2), and VAS (ACJ 0.5 ± 0.9; BR 0.5 ± 0.8; RC 0.5 ± 0.8). Overall, the CG showed no significant side-to-side difference in COP, whereas the ACJ-group and the BR-group demonstrated significantly increased COP compared to the healthy side (ACJ 103 cm vs. 98 cm, p = 0.049; BR: 116 cm vs. 102 cm, p = 0.006). The RC-group revealed no significant side-to-side difference (120 cm vs. 108 cm, n.s.). CONCLUSION: Centre of pressure measurement detected sensorimotor functional deficits following surgical treatment of the shoulder joint in patients with confirmed successful clinical and functional outcomes. This may indicate that specific postoperative training and rehabilitation protocols should be established for patients who underwent surgery of the upper extremity. These results underline that sensorimotor training should be an important component of postoperative rehabilitation and physiotherapeutic activities to improve postoperative function and joint control. LEVEL OF EVIDENCE: IV.

Increased Glenohumeral Joint Loads Due to a Supraspinatus Tear Can Be Reversed With Rotator Cuff Repair: A Biomechanical Investigation.

PURPOSE: To evaluate the effect of an isolated full-thickness supraspinatus (SSP) tear on glenohumeral kinematics and contact mechanics, as well as to quantify improvement following rotator cuff repair (RCR). METHODS: Ten fresh-frozen cadaveric shoulders (mean age: 63.1 ± 4.6 years) were tested using a dynamic shoulder simulator. A pressure-mapping sensor was placed between the humeral head and the glenoid. Each specimen underwent the following three conditions: 1) native, 2) isolated full-thickness SSP tear, and 3) RCR. Maximum abduction angle (MAA) and superior humeral head migration (SHM) were measured using 3D motion tracking software. Cumulative deltoid force (CDF) and glenohumeral contact mechanics, including contact area (GCA) and contact pressure (GCP), were assessed at the resting position, as well as at 15°, 30°, 45°, and 60° of glenohumeral abduction. RESULTS: Compared to native, the SSP tear resulted in a significant decrease in MAA (Δ-8.3°; P < .001) along with a SHM of 6.4 ± 3.8 mm, while significantly increasing CDF (Δ20.5 N; P = .008), GCP (Δ63.1 kPa; P < .001), and peak GCP (Δ278.6 kPa; P < .001), as well as decreasing GCA (Δ-45.8 mm2; P < .001) at each degree of abduction. RCR reduced SHM to 1.2 ± 2.5 mm, while restoring native MAA, CDF (Δ1.8 N), GCA (Δ4.5 mm2), GCP (Δ-4.5 kPa) and peak GCP (Δ19.9 kPa) at each degree of abduction (P > .999, respectively). CONCLUSION: In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. More specifically, RCR restored native glenohumeral contact area and contact pressure, while preventing superior humeral head migration and decreasing compensatory deltoid forces. CLINICAL RELEVANCE: These time 0 observations indicate that undergoing rotator cuff repair may prevent the development of degenerative changes by significantly reducing glenohumeral joint loads and ensuring sufficiently stable joint kinematics.

Minimum 10-Year Clinical Outcomes After Arthroscopic 270° Labral Repair in Traumatic Shoulder Instability Involving Anterior, Inferior, and Posterior Labral Injury.

BACKGROUND: Current literature reports highly satisfactory short- and midterm clinical outcomes in patients with arthroscopic 270° labral tear repairs. However, data remain limited on long-term clinical outcomes and complication and redislocation rates in patients with traumatic shoulder instability involving anterior, inferior, and posterior labral injury. PURPOSE: To investigate, at a minimum follow-up of 10 years, the clinical outcomes, complications, and recurrent instability in patients with 270° labral tears involving the anterior, inferior, and posterior labrum treated with arthroscopic stabilization using suture anchors. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective outcomes study was completed for all patients with a minimum 10-year follow-up who underwent arthroscopic 270° labral tear repairs with suture anchors by a single surgeon. Outcome measures included pre- and postoperative Rowe score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test, visual analog scale for pain, and Single Assessment Numeric Evaluation (SANE). Western Ontario Shoulder Instability Index (WOSI) scores were collected postoperatively. Complication data were collected, including continued instability, subluxation or dislocation events, and revision surgery. Failure was defined as any cause of revision surgery. RESULTS: In total, 21 patients (mean ± SD age, 27.1 ± 9.6 years) with 270° labral repairs were contacted at a minimum 10-year follow-up. All outcome measures showed statistically significant improvements as compared with those preoperatively: Rowe (53.9 ± 11.4 to 88.7 ± 8.9; P = .005), ASES (72.9 ± 18.4 to 91.8 ± 10.8; P = .004), Simple Shoulder Test (8.7 ± 2.4 to 11.2 ± 1.0; P = .013), visual analog scale (2.5 ± 2.6 to 0.5 ± 1.1; P = .037), and SANE (24.0 ± 15.2 to 91.5 ± 8.3; P = .043). The mean postoperative WOSI score at minimum follow-up was 256.3 ± 220.6. Three patients had postoperative complications, including a traumatic subluxation, continued instability, and a traumatic dislocation, 2 of which required revision surgery (14.2% failure rate). CONCLUSION: Arthroscopic repairs of 270° labral tears involving the anterior, inferior, and posterior labrum have highly satisfactory clinical outcomes at 10 years, with complication and redislocation rates similar to those reported at 2 years. This suggests that repairs of extensile labral tears are effective in restoring and maintaining mechanical stability of the glenohumeral joint in the long term.

Negligible Correlation between Radiographic Measurements and Clinical Outcomes in Patients Following Primary Reverse Total Shoulder Arthroplasty.

Previous attempts to measure lateralization, distalization or inclination after reverse total shoulder arthroplasty (rTSA) and to correlate them with clinical outcomes have been made in the past years. However, this is considered to be too demanding and challenging for daily clinical practice. Additionally, the reported findings were obtained from heterogeneous rTSA cohorts using 145° and 155° designs and are limited in external validity. The purpose of this study was to investigate the prognostic preoperative and postoperative radiographic factors affecting clinical outcomes in patients following rTSA using a 135° prosthesis design. In a multi-center design, patients undergoing primary rTSA using a 135° design were included. Radiographic analysis included center of rotation (COR), acromiohumeral distance (AHD), lateral humeral offset (LHO), distalization shoulder angle (DSA), lateralization shoulder angle (LSA), critical shoulder angle (CSA), and glenoid and baseplate inclination. Radiographic measurements were correlated to clinical and functional outcomes, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (STT), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) score, active forward elevation (AFE), external rotation (AER), and abduction (AABD), at a minimum 2-year follow-up. There was a significant correlation between both DSA (r = 0.299; p = 0.020) and LSA (r = -0.276; p = 0.033) and the degree of AFE at final follow-up. However, no correlation between DSA (r = 0.133; p = 0.317) and LSA (r = -0.096; p = 0.471) and AER was observed. Postoperative AHD demonstrated a significant correlation with final AFE (r = 0.398; p = 0.002) and SST (r = 0.293; p = 0.025). Further, postoperative LHO showed a significant correlation with ASES (r = -0.281; p = 0.030) and LSA showed a significant correlation with ASES (r = -0.327; p = 0.011), SANE (r = -0.308, p = 0.012), SST (r = -0.410; p = 0.001), and VAS (r = 0.272; p = 0.034) at terminal follow-up. All other correlations were found to be non-significant (p > 0.05, respectively). Negligible correlations between pre- and postoperative radiographic measurements and clinical outcomes following primary rTSA using a 135° prosthesis design were demonstrated; however, these observations are of limited predictive value for outcomes following rTSA. Subsequently, there remains a debate regarding the ideal placement of the components during rTSA to most sufficiently restore active ROM while minimizing complications such as component loosening and scapular notching. Additionally, as the data from this study show, there is still a considerable lack of data in assessing radiographic prosthesis positioning in correlation to clinical outcomes. As such, the importance of radiographic measurements and their correlation with clinical and functional outcomes following rTSA may be limited.

Comparison of Different Fixation Techniques of the Long Head of the Biceps Tendon in Superior Capsule Reconstruction for Irreparable Posterosuperior Rotator Cuff Tears: A Dynamic Biomechanical Evaluation.

BACKGROUND: In the past decade, superior capsular reconstruction has emerged as a potential surgical approach in young patients with irreparable posterosuperior rotator cuff tears (RCT) and absence of severe degenerative changes. Recently, the use of locally available and biological viable autografts, such as the long head of the biceps tendon (LHBT) for SCR has emerged, with promising early results. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effect of using the LHBT for reconstruction of the superior capsule on shoulder kinematics, along with different fixation constructs in a dynamic biomechanical model. The authors hypothesized that each of the 3 proposed fixation techniques would restore native joint kinematics, including glenohumeral superior translation (ghST), maximum abduction angle (MAA), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP). STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric shoulders (mean age, 53.4 ± 14.2 years) were tested using a dynamic shoulder simulator. Each specimen underwent the following 5 conditions: (1) intact, (2) irreparable posterosuperior rotator cuff tear (psRCT), (3) V-shaped LHBT reconstruction, (4) box-shaped LHBT reconstruction, and (5) single-stranded LHBT reconstruction. MAA, ghST, cDF and sCP were assessed in each tested condition. RESULTS: Each of the 3 LHBT techniques for reconstruction of the superior capsule significantly increased MAA while significantly decreasing ghST and cDF compared with the psRCT (P < .001 and P < .001, respectively). Additionally, the V-shaped and box-shaped techniques significantly decreased sCP (P = .009 and P = .016, respectively) compared with the psRCT. The V-shaped technique further showed a significantly increased MAA (P < .001, respectively) and decreased cDF (P = .042 and P = .039, respectively) when compared with the box-shaped and single-stranded techniques, as well as a significantly decreased ghST (P = .027) when compared with the box-shaped technique. CONCLUSION: In a dynamic biomechanical cadaveric model, using the LHBT for reconstruction of the superior capsule improved shoulder function by preventing superior humeral migration, decreasing deltoid forces and sCP. As such, the development of rotator cuff tear arthropathy in patients with irreparable psRCTs could potentially be delayed. CLINICAL RELEVANCE: Using a biologically viable and locally available LHBT autograft is a cost-effective, potentially time-saving, and technically feasible alternative for reconstruction of the superior capsule, which may result in favorable outcomes in irreparable psRCTs. Moreover, each of the 3 techniques restored native shoulder biomechanics, which may help improve shoulder function by preventing superior humeral head migration and the development of rotator cuff tear arthropathy in young patients with irreparable rotator cuff tears.

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.

PURPOSE: To 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. METHODS: This 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. RESULTS: Ten 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). CONCLUSIONS: Patients 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 EVIDENCE: Level IV, therapeutic case series.

High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members.

PURPOSE: To develop a consensus on diagnosis and treatment of acromioclavicular joint instability. METHODS: A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data. RESULTS: A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similar CONCLUSION: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified. LEVEL OF EVIDENCE: Level V.

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

PURPOSE: 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. METHODS: 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. RESULTS: Forty-two patients (mean age: 42.7 ± 12.8 years) were included in the study with an average follow-up of 3.8 ± 3.1 years (range: 1.1-11.5 years). 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 ± 3.9 mm, with no significant correlation to clinical outcomes scores. Complications occurred in 33.3% of cases, with postoperative heterotopic ossification being most frequent (14.3%). CONCLUSION: Patients undergoing ACCR using free tendon allografts for chronic ACJ injuries achieved significant improvement in shoulder function at a mean follow-up of 3.8 years. 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. LEVEL OF EVIDENCE: IV.