Clinical, Radiographic, and Surgical Presentation of Subscapularis Tendon Tears: A Retrospective Analysis of 139 Patients.

PURPOSE: To analyze and correlate the clinical, radiographic, and surgical presentation of subscapularis (SSc) tears treated with arthroscopic repair. METHODS: We retrospectively identified 455 patients who underwent rotator cuff tear repairs at our institution from 2010 to 2014. Of these patients, 139 underwent an SSc repair either in isolation or concurrently with other rotator cuff procedures. Tear size was classified arthroscopically by whether tears involved the superior one-third of the SSc tendon, superior two-thirds of the SSc tendon, or complete SSc tendon. Patient demographic characteristics, assessments of belly-press weakness and the lift-off test, magnetic resonance imaging (MRI) findings, and data on concurrent supraspinatus and biceps tendon pathology were collected and analyzed according to tear size. RESULTS: Our cohort had a mean age of 61.8 ± 12.5 years, with a male-female gender ratio of 1.7:1. There were 22 tears of the superior one-third of the SSc (16%), 96 tears of the superior two-thirds of the SSc (69%), and 21 complete SSc tears (15%). Overall, MRI diagnosis of SSc tears had a sensitivity of 83% and specificity of 70%. MRI sensitivity was associated with tear severity (P = .02), with complete tears having an MRI sensitivity of 100%; superior two-thirds, 82%; and superior one-third, 67%. Physical examination sensitivity for belly-press weakness and the lift-off test was 61% and 63%, respectively, and did not correspond with tear size. Increased SSc tear size corresponded with a history of trauma (P = .04) and the presence of concurrent supraspinatus tears (P = .03) and biceps pathology (P = .003). CONCLUSIONS: The diagnosis of SSc tears remains challenging because of the limited sensitivity of MRI and physical examination. The diagnostic sensitivity of MRI is associated with SSc tear size, whereas physical examination is independent of tear size. Additional associations identified in this study include increased SSc tear size corresponding with a history of trauma, presence of concurrent supraspinatus tears, and presence of concurrent biceps tendon pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Plate fixation of midshaft clavicular fractures: patient-reported outcomes and hardware-related complications.

BACKGROUND: Recent studies report high hardware removal rates after plate fixation of midshaft clavicular fractures. Precontoured clavicle plates may decrease hardware-related complications while improving healing rates and patient-reported outcomes (PROs). METHODS: Using a private-payer national database, we identified 7826 patients who underwent clavicle open reduction and internal fixation (ORIF) in 2007 to 2011. Database patients were tracked for 2 years to assess hardware removal and revision fixation. In addition, we retrospectively identified 73 patients who underwent plate fixation of midshaft clavicular fractures at our institution. These patients completed the Disabilities of Arm, Shoulder and Hand (DASH) assessment, the EQ-5D (EuroQol, Rotterdam, The Netherlands) quality of life assessment, and a hardware-related outcomes survey. RESULTS: Among 7826 database patients, 994 (12.7%) underwent hardware removal and 78 (1%) required revision ORIF. The annual incidence of clavicle ORIF increased 61.5% between 2007 and 2011. In our institutional cohort, 56 patients (77%) were fixed with precontoured plates and 17 (23%) with standard plates. At a mean follow-up of 4.2 years, 11 patients (15%) underwent hardware removal and 1 patient (1.4%) experienced nonunion. Patients reported excellent outcomes, with average DASH of 4.0 ± 8.9 and EQ-5D of 0.89 ± 0.19. There were no differences in PROs, hardware removal, or union rate between plate types, although our study was underpowered for these outcomes. Patients who underwent hardware removal reported lower DASH, EQ-5D, satisfaction, and shoulder function compared with patients with hardware retained. Women were more likely to undergo hardware removal in the institutional (P = .009) and the database (P < .001) cohorts. CONCLUSION: Displaced midshaft clavicle fractures have high union rates with precontoured plate fixation. Women are 4 times more likely than men to have hardware removed. Patients undergoing clavicle hardware removal report worse long-term outcomes than patients with hardware retained.

Outcomes after shoulder replacement: comparison between reverse and anatomic total shoulder arthroplasty.

BACKGROUND: Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) are increasingly common procedures employed to treat arthritic conditions. Although TSA is a widely accepted procedure for glenohumeral arthritis with intact rotator cuff, concerns about RTSA persist because of variable complication rates and outcomes. METHODS: This is a prospective, case-control study comparing outcomes and complications after TSA and RTSA. The study included 47 patients undergoing TSA for glenohumeral arthritis and 53 patients undergoing RTSA for rotator cuff tear arthropathy. Average clinical follow-up was more than 2 years in both groups. Major complications included infection, periprosthetic fracture, instability, glenoid loosening, and need for revision surgery. Patient outcome measures included the American Shoulder and Elbow Surgeons score, pain visual analog scale score, and goniometer-measured range of motion. Plain radiographs were reviewed to assess for degree of glenoid lucency in TSA and scapular notching in RTSA. RESULTS: At 2 years, there were no differences in rate of major complications (TSA, 15%; RTSA, 13%; P = .808) or revision surgeries (TSA, 11%; RTSA, 9%). Outcomes assessed by the American Shoulder and Elbow Surgeons score and visual analog scale were also similar between the 2 groups. TSA patients had greater external rotation than RTSA patients did (53° vs 38°; P = .001). Otherwise, forward flexion, abduction, and internal rotation were comparable in range of motion. CONCLUSIONS: TSA and RTSA have similar complication rates, need for revision, patient-reported outcomes, and range of motion at 2 years of follow-up. The use of side-by-side cohorts in this study allows standardized comparison between these 2 shoulder arthroplasty procedures.

Lateral Center-Edge Angle Is Not Predictive of Acetabular Articular Cartilage Surface Area: Anatomic Variation of the Lunate Fossa.

BACKGROUND: Surgical treatment of symptomatic femoroacetabular impingement (FAI) and dysplasia requires careful characterization of acetabular morphology. The lateral center-edge angle (LCEA) is often used to assess lateral acetabular anatomy. Previous work has questioned the LCEA as a surrogate for acetabular contact/articular cartilage surface area because of the variable morphology of the lunate fossa. HYPOTHESIS: We hypothesized that weightbearing articular cartilage of the acetabulum would poorly correlate with LCEA secondary to significant variation in the size of the lunate fossa. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Patients with 3D CT imaging undergoing either hip arthroscopy or periacetabular osteotomy for FAI or symptomatic hip instability were retrospectively identified. The LCEA and femoral head diameter were measured on an anteroposterior pelvis radiograph. Patients were grouped according to their lateral acetabular coverage as undercoverage (LCEA, <25°), normal coverage (LCEA, 25°-40°), or overcoverage (LCEA, >40°). Patients were randomly identified until each group contained 20 patients. The articular surface area was measured from preoperative 3D CT data. Linear regression analysis was performed to examine the relationship between articular surface area and LCEA. Continuous and categorical data were analyzed utilizing analysis of variance and chi-square analysis. Statistical significance was set at P < .05. RESULTS: No difference in age (P = .52), body mass index (BMI) (P = .75), or femoral head diameter (P = .66) was noted between groups. A significant difference in articular surface area was observed between patients with undercoverage and those with overcoverage (20.4 cm2 vs 24.5 cm2; P = .01). No significant difference was identified between the undercoverage and normal groups (20.4 cm2 vs 23.3 cm2; P = .09) or the normal and overcoverage groups (23.3 cm2 vs 24.5 cm2; P = .63). A moderate positive correlation was observed between LCEA and articular surface area across all patients (r = 0.38; P = .002) but not when patients with undercoverage were excluded (r = 0.02; P = .88). Significant variation in surface area was observed within each group such that no patient in any group was outside of 2 SDs of the means of the other groups. When patients were categorized into quartiles established by the articular surface area for the entire population, 40% of patients with overcoverage were observed in the first or second quartile (lower area). CONCLUSION: Lateral acetabular undercoverage based on the LCEA (<25°) correlates with decreased acetabular surface area. Normal or increased acetabular coverage (LCEA, >25°), however, is not predictive of increased, normal, or decreased acetabular surface area.

Effect of Muscle Quality on Operative and Nonoperative Treatment of Rotator Cuff Tears.

BACKGROUND: Rotator cuff muscle atrophy and fatty infiltration are predictors of negative outcomes after rotator cuff repair. However, the impact of muscle degeneration on nonsurgical treatment is unknown. HYPOTHESIS: Rotator cuff muscle atrophy and fatty infiltration will reduce the outcomes of operative repair while having a minimal effect on nonsurgical treatment. Additionally, in the setting of atrophy and fatty infiltration, surgical and nonsurgical treatment will produce equivalent outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing operative and nonoperative treatment of full-thickness rotator cuff tears were prospectively enrolled into a nonrandomized cohort study. Muscle quality was assessed on magnetic resonance imaging by use of the supraspinatus tangent sign, Warner atrophy, and Goutallier fatty infiltration classifications. Grading was performed by 2 independent observers who were blinded to patient treatment and outcomes. Normalized Western Ontario Rotator Cuff (WORC) index was the primary patient-reported outcome. Multivariate linear regression analysis was used to determine the impact of muscle quality on treatment outcomes. RESULTS: The cohort consisted of 157 patients, 89 (57%) surgical and 68 (43%) nonsurgical, with a mean follow-up of 2.4 years (range, 1-5 years). Tangent sign had the best inter- and intrarater reliability, with kappa statistics of 0.81 and 0.86, respectively. Reliability for Warner atrophy was 0.69 to 0.76 and for Goutallier classification was 0.54 to 0.64. Overall, improvement in WORC scores was higher in the surgical group than the nonsurgical group (39.3 vs 21.2; P < .001). A positive tangent sign was the only independent predictor (P < .01) of worse outcomes in the surgical group, accounting for an estimated 22-point lower improvement in WORC scores. CONCLUSION: A positive tangent sign was predictive of worse operative outcomes, resulting in equivalent improvements between surgical and nonsurgical treatment. The tangent sign is a reliable, prognostic indicator that clinicians can use when counseling patients on the optimal treatment of rotator cuff tears.

Clinical Outcomes After Anterior Shoulder Stabilization in Overhead Athletes: An Analysis of the MOON Shoulder Instability Consortium.

BACKGROUND: Traumatic anterior shoulder instability is a common condition affecting sports participation among young athletes. Clinical outcomes after surgical management may vary according to patient activity level and sport involvement. Overhead athletes may experience a higher rate of recurrent instability and difficulty returning to sport postoperatively with limited previous literature to guide treatment. PURPOSE: To report the clinical outcomes of patients undergoing primary arthroscopic anterior shoulder stabilization within the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Consortium and to identify prognostic factors associated with successful return to sport at 2 years postoperatively. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Overhead athletes undergoing primary arthroscopic anterior shoulder stabilization as part of the MOON Shoulder Instability Consortium were identified for analysis. Primary outcomes included the rate of recurrent instability, defined as any patient reporting recurrent dislocation or reoperation attributed to persistent instability, and return to sport at 2 years postoperatively. Secondary outcomes included the Western Ontario Shoulder Instability Index and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow questionnaire score. Univariate regression analysis was performed to identify patient and surgical factors predictive of return to sport at short-term follow-up. RESULTS: A total of 49 athletes were identified for inclusion. At 2-year follow-up, 31 (63%) athletes reported returning to sport. Of those returning to sport, 22 athletes (45% of the study population) were able to return to their previous levels of competition (nonrefereed, refereed, or professional) in at least 1 overhead sport. Two patients (4.1%) underwent revision stabilization, although 14 (28.6%) reported subjective apprehension or looseness. Age ( P = .87), sex ( P = .82), and baseline level of competition ( P = .37) were not predictive of return to sport. No difference in range of motion in all planes ( P > .05) and Western Ontario Shoulder Instability Index scores (78.0 vs 80.1, P = .73) was noted between those who reported returning to sport and those who did not. CONCLUSION: Primary arthroscopic anterior shoulder stabilization in overhead athletes is associated with a low rate of recurrent stabilization surgery. Return to overhead athletics at short-term follow-up is lower than that previously reported for the general athletic population.

Impact of smoking on patient outcomes after arthroscopic rotator cuff repair.

BACKGROUND: Cigarette smoking may adversely affect rotator cuff tear pathogenesis and healing. However, the impact of cigarette smoking on outcomes after arthroscopic rotator cuff repair is relatively unknown. PATIENTS AND METHODS: A cohort of 126 patients who underwent arthroscopic rotator cuff repair with minimum 2 years follow-up were retrospectively identified from our institutional database. Patient demographics, comorbidities, and cuff tear index were collected at initial presentation. Outcome measures including American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) score and Visual Analogue Scale (VAS) for pain were collected at each clinical follow-up. Mixed model regression analysis was used to determine the impact of smoking on outcomes, while controlling for tear size and demographics. RESULTS: In our cohort, 14% were active or recent smokers. At baseline, smokers presented with higher pain, greater comorbidities and worse ASES scores than non-smokers. Smokers also had a non-significant trend towards presenting for surgical repair at a younger age and with larger tear sizes. Both smokers and non-smokers had statistical improvements in outcomes at 2 years following repair. Regression analysis revealed that smokers had a worse improvement in ASES but not WORC or VAS pain scores after surgery. CONCLUSION: The minimal clinically important difference was achieved for ASES, WORC and VAS pain in both smokers and non-smokers, suggesting both groups substantially benefit from arthroscopic rotator cuff repair. Smokers tend to present with larger tears and worse initial outcome scores, and they have a lower functional improvement in response to surgery.

Knee Function Assessment in Patients With Meniscus Injury: A Preliminary Study of Reproducibility, Response to Treatment, and Correlation With Patient-Reported Questionnaire Outcomes.

BACKGROUND: Outcomes of meniscus surgery are typically assessed with patient questionnaires that help capture symptoms and functional limitations but may not provide an accurate representation of underlying joint health. There are currently no performance-based measures of knee function in patients with symptomatic meniscus injury. PURPOSE: To assess the reproducibility, response to partial meniscectomy, and correlation with patient-reported questionnaire outcomes of novel performance-based knee function tests. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A battery of 9 tests for activities that require knee movements essential for everyday living was developed. Intra- and interrater reproducibility was assessed in 50 meniscus tear patients completing the battery at 2 preoperative assessments with either the same or different examiners. Response to arthroscopic partial meniscectomy was evaluated in 35 of these patients 6 weeks after surgery. Subjects also completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) questionnaires pre- and postoperatively. RESULTS: The intrarater intraclass correlation coefficients (ICCs) were excellent for all tests (ICC > 0.8). Interrater ICC > 0.8 was observed for step-down, stair descent, star lunges, and timed treadmill travel. Performance on all tests improved significantly with surgery (P < .05), with the greatest improvement in sit-to-stand and stair ascent and descent. A greater percentage response to surgery was seen on questionnaire outcomes (20%-65%) than on performance-based tests (3%-15%). Moderate to poor correlations existed between the KOOS activities of daily living subscale and the performance-based tests (all ICCs ≤ 0.4). CONCLUSION: Performance-based knee function tests demonstrated good reproducibility and responsiveness in patients undergoing partial meniscectomy. CLINICAL RELEVANCE: As both patient perception and functional performance are determinants of patient outcomes, questionnaires and performance-based tests could be used simultaneously to provide complementary data to monitor short- and long-term outcomes after meniscus surgery.