Determining the Patient Acceptable Symptom State (PASS) for Shoulder Strength After Subscapularis Arthroscopic Repair and Evaluating the Preoperative Predictors for PASS Achievement.

Background: Restoring shoulder strength after arthroscopic rotator cuff repair (ARCR) is critical, but there is limited understanding as to what patients consider satisfactory postoperative strength. Purpose: To determine the Patient Acceptable Symptom State (PASS) values for the Constant score strength parameter and internal rotation (IR) strength in patients who underwent ARCR for rotator cuff tears involving the subscapularis (SSC) muscle and evaluate for associations between preoperative and intraoperative patient characteristics with PASS achievement. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis was conducted on prospectively collected data for 278 patients with an SSC tear (isolated or combined) who underwent ARCR and had minimum 2-year follow-up data. Functional outcomes (patient-reported outcomes, range of motion, Constant strength, and IR strength) were assessed preoperatively and at the latest follow-up. The overall, male, and female PASS values for postoperative strength measures were evaluated using receiver operating characteristic analysis. Correlation and logistic regression analyses were used to evaluate the relationship between preoperative variables and PASS achievement for Constant and IR strengths. Results: The mean follow-up time was 72.8 months. The overall, male, and female PASS values were 9.9 lb (4.5 kg), 14.5 lb (6.6 kg), and 8.5 lb (3.9 kg), respectively, for Constant strength and 15.2 lb (6.9 kg), 20.7 lb (9.4 kg), and 12.1 lb (5.5 kg), respectively, for IR strength. Older age, high fatty infiltration of the SSC tendon (Goutallier grades 3 and 4), and failure of SSC healing correlated negatively with PASS attainment for the strength measures. High fatty infiltration of the supraspinatus and infraspinatus muscles correlated negatively with Constant strength. Decreased coracohumeral distance (CHD) and larger SSC tears correlated negatively with achieving PASS for IR strength. Workers' compensation, high supraspinatus and SSC fatty infiltration, and the use of knotted suture anchors were predictors of not achieving the overall Constant strength PASS, while lower SSC fatty infiltration and high CHD were predictors of achieving the overall IR strength PASS. Conclusion: This study established the PASS values for Constant and IR strengths for patients after ARCR involving the SSC tendon. Workers' compensation, high supraspinatus and SSC fatty infiltration, and the use of knotted suture anchors were predictors of not achieving the overall Constant strength PASS, while lower SSC fatty infiltration and high CHD were predictors of achieving the overall IR strength PASS.

Long head of biceps tendon management in the setting of massive rotator cuff tears.

Pathology of the long head of the biceps tendon is commonly associated with massive rotator cuff tears (MRCTs), which account for roughly one third of all rotator cuff tears. Treatment options for this condition include tenotomy, tenodesis, augmentation, and the use of the tendon as a graft for partial superior capsule reconstruction. Augmentation and superior capsular reconstruction are evolving techniques in the management of MRCTs. However, similar to the lack of consensus on the treatment of MRCTs, there are no clear guidelines for the management of concurrent biceps tendon pathology.

SECEC Grammont Award 2024: The critical role of posture adjustment for range of motion simulation in reverse total shoulder arthroplasty preoperative planning.

Aims: The objective of this study was to compare simulated range of motion (ROM) for reverse total shoulder arthroplasty (rTSA) with and without adjustment for scapulothoracic orientation in a global reference system. We hypothesized that values for simulated ROM in preoperative planning software with and without adjustment for scapulothoracic orientation would be significantly different. Methods: A statistical shape model of the entire humerus and scapula was fitted into ten shoulder CT scans randomly selected from 162 patients who underwent rTSA. Six shoulder surgeons independently planned a rTSA in each model using prototype development software with the ability to adjust for scapulothoracic orientation, the starting position of the humerus, as well as kinematic planes in a global reference system simulating previously described posture types A, B, and C. ROM with and without posture adjustment was calculated and compared in all movement planes. Results: All movement planes showed significant differences when comparing protocols with and without adjustment for posture. The largest mean difference was seen in external rotation, being 62° (SD 16°) without adjustment compared to 25° (SD 9°) with posture adjustment (p < 0.001), with the highest mean difference being 49° (SD 15°) in type C. Mean extension was 57° (SD 18°) without adjustment versus 24° (SD 11°) with adjustment (p < 0.001) and the highest mean difference of 47° (SD 18°) in type C. Mean abducted internal rotation was 69° (SD 11°) without adjustment versus 31° (SD 6°) with posture adjustment (p < 0.001), showing the highest mean difference of 51° (SD 11°) in type C. Conclusion: The present study demonstrates that accounting for scapulothoracic orientation has a significant impact on simulated ROM for rTSA in all motion planes, specifically rendering vastly lower values for external rotation, extension, and high internal rotation. The substantial differences observed in this study warrant a critical re-evaluation of all previously published studies that examined component choice and placement for optimized ROM in rTSA using conventional preoperative planning software.

The Reverse Fragility Index: Interpreting the Evidence for Arthroscopic Rotator Cuff Repair Healing Associated With Early Versus Delayed Mobilization.

Background: The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines (CPGs) note "strong" evidence that early and delayed mobilization protocols after small to medium arthroscopic rotator cuff repairs achieve similar rotator cuff healing rates. Purpose: We utilized the reverse fragility index (RFI) to assess the fragility of randomized controlled trials (RCTs) reporting no statistically significant difference in tendon re-tear rates after rotator cuff repair in those undergoing early versus delayed rehabilitation. Methods: Randomized controlled trials used in the most recent AAOS CPGs on the timing of postoperative mobilization after arthroscopic rotator cuff repairs were analyzed. Only RCTs with a reported P value ≥ .05 were included. The RFI at a threshold of P < .05 was calculated for each study. The reverse fragility quotient (RFQ) was calculated by dividing the RFI by the study sample size. Results: In 6 clinical trials with a total of 542 patients, the number of tendon re-tear events was 48. The median RFI at the P < .05 threshold was 4 (range: 3.25-4.75), and the median RFQ was .05 (range: 0.03-0.08). The median loss to follow-up was 6 patients. Of the 6 studies investigated, 3 reported a loss to follow-up greater than their respective RFI. Conclusion: The equivalence in rotator cuff repair healing rates associated with early and delayed mobilization protocols rests on fragile studies, as their statistical non-significance can be reversed by changing the outcome status of only a handful of patients. Consideration should be given to the routine reporting of RFI in clinical practice guidelines including RCTs with statistically non-significant results.

Compression of an Autograft Biceps into an Augmentation Patch does not Cause Mechanical Damage to the Tenocyte.

PURPOSE: A compression plate has recently been reported as a point of care processor for adapting the long head of the biceps into an autograft patch for rotator cuff augmentation. The purpose of this study was to evaluate the effects of this graft preparation technique on histological evidence of tenocyte mechanical damage. METHODS: A consecutive series of patients undergoing biceps tenodesis for shoulder pathology were evaluated. After supra-pectoral tenodesis, 27 mm of the long head of the biceps was secured for compression into the patch. The remaining length of residual tendon was longitudinally split, resulting in two equal lengths of remnant tendon from the same zone. One sample was sent to pathology with no preparation, and the other was prepared as a compressed biceps autograft patch according to the manufacturer's recommendations. Both grafts were sent to pathology for evaluation of tenocyte morphology. Records were reviewed to determine if compression resulted in mechanical damage to the tenocytes at the time of biceps augmentation. RESULTS: 55 shoulder procedures and 110 samples were sent for pathology analysis. 42 of the 55 (76%) specimens demonstrated morphologically normal tenocytes in both the compressed and non-compressed groups, and 7 (13%) cases showed evidence of tenocyte necrosis or mechanical damage in both groups. The difference abnormal tenocyte morphology between the compressed group and the native group was not statistically significant (p=0.625). CONCLUSION: Autograft biceps compression into a point of care patch did not result in mechanical damage to tenocyte morphology at the time of insertion for augmentation of rotator cuff pathology. CLINICAL RELEVANCE: Free proximal biceps tendon compression can result in a patch that does not mechanically damage the tenocyte. The patch can be used as a biologic autograft to enhance shoulder rotator cuff repair, as well as subscapularis repair in the setting of shoulder arthroplasty.

High Variability in Standardized Outcome Thresholds of Clinically Important Changes in Shoulder Instability Surgery: A Systematic Review.

PURPOSE: To examine reported minimal clinically important difference (MCID) and patient-acceptable satisfactory state (PASS) values for patient-reported outcome measures (PROMs) after shoulder instability surgery and assess variability in published values depending on the surgery performed. Our secondary aims were to describe the methods used to derive MCID and PASS values in the published literature, including anchor-based, distribution-based, or other approaches, and to assess the frequency of MCID and PASS use in studies on shoulder instability surgery. METHODS: A systematic review of MCID and PASS values after Bankart, Latarjet, and Remplissage procedures was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The Embase, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were queried from 1985 to 2023. Inclusion criteria included studies written in English and studies reporting use of MCID or PASS for patient-reported outcome measures (PROMS) after Latarjet, Bankart, and Remplissage approaches for shoulder instability surgery. Extracted data included study population characteristics, intervention characteristics, and outcomes of interest. Continuous data were described using medians and ranges. Categorical variables, including PROMs and MCID/PASS methods, were described using percentages. Because MCID is a patient-level rather than a group-level metric, the authors confirmed that all included studies reported proportions (%) of subjects who met or exceeded the MCID. RESULTS: A total of 174 records were screened, and 8 studies were included in this review. MCID was the most widely used outcome threshold and was reported in all 8 studies, with only 2 studies reporting both the MCID and the PASS. The most widely studied PROMs were the American Shoulder and Elbow Surgeons (range 5.65-9.6 for distribution MCID, 8.5 anchor MCID, 86 anchor PASS); Single Assessment Numeric Evaluation (range 11.4-12.4 distribution MCID, 82.5-87.5 anchor PASS); visual analog scale (VAS) (range 1.1-1.7 distribution MCID, 1.5-2.5 PASS); Western Ontario Shoulder Instability Index (range 60.7-254.9 distribution MCID, 126.43 anchor MCID, 571-619.5 anchor PASS); and Rowe scores (range 5.6-8.4 distribution MCID, 9.7 anchor MCID). Notably, no studies reported on substantial clinical benefit or maximal outcome improvement. CONCLUSIONS: Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. Although MCID has been the most frequently reported metric, there is considerable interstudy variability observed in their values. CLINICAL RELEVANCE: Knowing the outcome thresholds such as MCID and PASS of the PROMs frequently used to evaluate the results of glenohumeral stabilization surgery is fundamental because they allow us to know what is a clinically significant improvement for the patient.

Machine Learning Models Can Define Clinically Relevant Bone Density Subgroups based on Patient Specific Calibrated CT Scans in Patients Undergoing Reverse Shoulder Arthroplasty.

BACKGROUND: Reduced bone density is recognized as a predictor for potential complications in reverse shoulder arthroplasty (RSA). While humeral and glenoid planning based on preoperative computed tomography (CT) scans assist in implant selection and position, reproducible methods for quantifying the patients' bone density are currently not available. The purpose of this study was to perform bone density analyses including patient specific calibration in an RSA cohort based on preoperative CT imaging. It was hypothesized that preoperative CT bone density measures would provide objective quantification of the patients' humeral bone quality. METHODS: This study consisted of three parts, (1) analysis of a patient-specific calibration method in cadaveric CT scans, (2) retrospective application in a clinical RSA cohort, and (3) clustering and classification with machine learning models. Forty cadaveric shoulders were scanned in a clinical CT and compared regarding calibration with density phantoms, air muscle, and fat (patient-specific) or standard Hounsfield unit. Post-scan patient-specific calibration was used to improve the extraction of three-dimensional regions of interest for retrospective bone density analysis in a clinical RSA cohort (n=345). Machine learning models were used to improve the clustering (Hierarchical Ward) and classification (Support Vector Machine (SVM)) of low bone densities in the respective patients. RESULTS: The patient-specific calibration method demonstrated improved accuracy with excellent intraclass correlation coefficients (ICC) for cylindrical cancellous bone densities (ICC>0.75). Clustering partitioned the training data set into a high-density subgroup consisting of 96 patients and a low-density subgroup consisting of 146 patients, showing significant differences between these groups. The SVM showed optimized prediction accuracy of low and high bone densities compared to conventional statistics in the training (accuracy=91.2%; AUC=0.967) and testing (accuracy=90.5 %; AUC=0.958) data set. CONCLUSION: Preoperative CT scans can be used to quantify the proximal humeral bone quality in patients undergoing RSA. The use of machine learning models and patient-specific calibration on bone mineral density demonstrated that multiple 3D bone density scores improved the accuracy of objective preoperative bone quality assessment. The trained model could provide preoperative information to surgeons treating patients with potentially poor bone quality.

Identification of ChatGPT-Generated Abstracts Within Shoulder and Elbow Surgery Poses a Challenge for Reviewers.

PURPOSE: To evaluate the extent to which experienced reviewers can accurately discern between artificial intelligence (AI)-generated and original research abstracts published in the field of shoulder and elbow surgery and compare this with the performance of an AI detection tool. METHODS: Twenty-five shoulder- and elbow-related articles published in high-impact journals in 2023 were randomly selected. ChatGPT was prompted with only the abstract title to create an AI-generated version of each abstract. The resulting 50 abstracts were randomly distributed to and evaluated by 8 blinded peer reviewers with at least 5 years of experience. Reviewers were tasked with distinguishing between original and AI-generated text. A Likert scale assessed reviewer confidence for each interpretation, and the primary reason guiding assessment of generated text was collected. AI output detector (0%-100%) and plagiarism (0%-100%) scores were evaluated using GPTZero. RESULTS: Reviewers correctly identified 62% of AI-generated abstracts and misclassified 38% of original abstracts as being AI generated. GPTZero reported a significantly higher probability of AI output among generated abstracts (median, 56%; interquartile range [IQR], 51%-77%) compared with original abstracts (median, 10%; IQR, 4%-37%; P < .01). Generated abstracts scored significantly lower on the plagiarism detector (median, 7%; IQR, 5%-14%) relative to original abstracts (median, 82%; IQR, 72%-92%; P < .01). Correct identification of AI-generated abstracts was predominately attributed to the presence of unrealistic data/values. The primary reason for misidentifying original abstracts as AI was attributed to writing style. CONCLUSIONS: Experienced reviewers faced difficulties in distinguishing between human and AI-generated research content within shoulder and elbow surgery. The presence of unrealistic data facilitated correct identification of AI abstracts, whereas misidentification of original abstracts was often ascribed to writing style. CLINICAL RELEVANCE: With rapidly increasing AI advancements, it is paramount that ethical standards of scientific reporting are upheld. It is therefore helpful to understand the ability of reviewers to identify AI-generated content.

Home-Based or Supervised Physical Therapy Shows Similar Functional Outcomes and Healing After Massive Rotator Cuff Repair.

PURPOSE: To compare postoperative clinical outcomes at the 3-month, 6-month, 12-month, and latest follow-up in patients undergoing supervised physical therapy (PT) or a home-based exercise program after arthroscopic repair (ARCR) of massive rotator cuff tears (MRCTs). METHODS: A retrospective review was conducted on a prospectively maintained database of patients who underwent either supervised PT or home-based therapy after ARCR of MRCTs between January 2015 and December 2018 at a single center with a minimum 24-month follow-up. At their 2-week postoperative routine follow-up, patients were allowed to choose between home-based and supervised PT. Patient-reported outcomes (PROs) and range of motion (ROM) were collected and compared between cohorts preoperatively and at the 3-month, 6-month, 12-month, and latest follow-up. The percentage of patients reaching or exceeding the minimal clinically important difference (MCID) and patient accepted symptomatic state (PASS) for visual analog scale for pain, American Shoulder and Elbow Surgeon (ASES) score, and Subjective Shoulder Value was recorded for both cohorts at each time point. Complications, healing, satisfaction, and return to work were reported. Healing was evaluated via ultrasound at the latest follow-up. RESULTS: Ninety-nine patients met the study criteria: 61 in the supervised PT cohort and 38 in the home-based cohort. The supervised PT and home-based cohorts returned to the clinic for their most recent follow-up at 53 ± 20 and 55 ± 16 months (P = .496) after surgery, respectively. There was no difference when comparing tendon involvement (supraspinatus, P = .574; infraspinatus, P = .288; subscapularis, P = .592), tear retraction (P = .603), or high-grade fatty infiltration (supraspinatus, P = .684; infraspinatus, P = .397; subscapularis, P = .473) based on preoperative magnetic resonance imaging assessment and surgery-related factors, including anterior (P = .473) or posterior (P = .386) slides, fixation constructs (P = .829), or complete repair (P = .912). Both cohorts showed similar PROs and ROM at baseline. Postoperative PROs and ROM were similar among groups at the 3-month, 6-month, 12-month, and latest follow-up. However, ASES (71.4 vs 61.2; P = .013) and forward flexion (135° vs 118°; P = .023) were significantly higher at 3-month follow-up in the home-based cohort. Both groups comparably achieved MCID and PASS for PROs at the 3-month, 6-month, and 12-month follow-up. At the latest follow-up, the supervised PT and home-based cohort achieved MCID and PASS for visual analog scale (75% vs 81%, P = .573; 70% vs 72%, P = .911), ASES (76% vs 74%, P = .777; 72% vs 72%, P = .873), and Subjective Shoulder Value (82% vs 84%, P = .734; 72% vs 66%, P = .489), respectively. Satisfaction, healing, complication, and return-to-work rates were similar. CONCLUSIONS: Patients undergoing rehabilitation using a home-based protocol showed largely similar functional scores and healing to those with supervised PT after ARCR of MRCTs at the latest follow-up. Although patients with home-based therapy achieved higher forward flexion and ASES at the 3-month follow-up, these became comparable starting at the 6-month postoperative mark. MCID and PASS were achieved similarly for PROs at each time point. LEVEL OF EVIDENCE: Level III, retrospective case series comparison.

Glenoid lateralization in reverse shoulder arthroplasty: metal vs. bone offset in different implant designs.

Background: Higher bone or metal glenoid offset in reverse shoulder arthroplasty (RSA) reduces scapular notching, improves range of motion (ROM), and reduces postoperative instability. This retrospective multicenter study compared two implant designs to evaluate the short-term clinical and radiologic results of bone increased offset RSA (BIO-RSA) and metal increased offset RSA (MIO-RSA) in reverse shoulder. We hypothesized no difference between groups. Methods: This study analyzed n = 62 BIO-RSA and n = 90 MIO-RSA cases with a mean follow-up of 29.7 ± 6.0 months (BIO-RSA, range 24-49 months) and 24.0 ± 1.1 months (MIO-RSA, range 22-28 months). A 145°-onlay humeral stem was utilized in BIO-RSA cases, while a 135°-semi-inlay humeral stem was implanted in all MIO-RSA cases. Preoperative and postoperative radiologic imaging was reviewed to identify signs of scapular notching. Additionally, lateralization was evaluated according to Erickson et al. The constant score, subjective shoulder value, and ROM were evaluated during the baseline and follow-up consultations, and the findings of both groups were subsequently compared. Results: Scapular notching was observed in 7.0% (n = 8) of MIO-RSA cases and 8.1% (n = 5) of BIO-RSA cases (P = .801). MIO-group had a higher lateralization angle (P = .020) and the BIO-group had a higher distalization angle (P = .005). At baseline, mean constant score in the MIO-RSA group was higher than in the BIO-RSA group (P < .001), and it significantly increased to 67.8 ± 12.1P (MIO-RSA) and 69.5 ± 12.3P (BIO-RSA) to a similar level (P = .399). ROM improved in both groups with no significant difference between the two groups at follow-up. Conclusion: BIO-RSA and MIO-RSA in two distinct implant designs provide comparable short-term outcomes with a similar increase in shoulder function with notable variations in the lateralization and distalization angles between both implants. Scapular notching was rarely seen and unaffected by the method of glenoid lateralization. Follow-up investigations of both techniques are necessary to complement and track changes in the long-term outcome.

A stemless anatomic shoulder arthroplasty design provides increased cortical medial calcar bone loading in variable bone densities compared to a short stem implant.

Background: Several studies have reported proximal bone resorption in stemless and press-fit short-stem humeral implants for anatomic total shoulder arthroplasty. The purpose of this biomechanical study was to evaluate implant and cortical bone micromotion of a cortical rim-supported stemless implant compared to a press-fit short stem implant during cyclic loading and static compression testing. Methods: Thirty cadaveric humeri were assigned to 3 groups based on a previously performed density analysis, adopting the metaphyseal and epiphyseal and inferior supporting bone densities for multivariate analyses. Implant fixation was performed in stemless implant in low bone density (SL-L, n = 10) or short stem implant in low bone density (Stem-L, n = 10) and in stemless implant in high bone density (SL-H, n = 10). Cyclic loading with 220 N, 520 N, and 820 N over 1000 cycles at 1.5 Hz was performed with a constant valley load of 25 N. Optical recording allowed for spatial implant tracking and quantification of cortical bone deformations in the medial calcar bone region. Implant micromotion was measured as rotational and translational displacement. Load-to-failure testing was performed at a rate of 1.5 mm/s with ultimate load and stiffness measured. Results: The SL-H group demonstrated significantly reduced implant micromotion compared to both low-density groups (SL-L: P = .014; Stem-L: P = .031). The Stem-L group showed significantly reduced rotational motion and variance in the test results at the 820-N load level compared to the SL-L group (equal variance: P = .012). Implant micromotion and reversible bone deformation were significantly affected by increasing load (P < .001), metaphyseal cancellous (P = .023, P = .013), and inferior supporting bone density (P = .016, P = .023). Absolute cortical bone deformation was significantly increased with stemless implants in lower densities and percentage reversible bone deformation was significantly higher for the SL-H group (21 ± 7%) compared to the Stem-L group (12 ± 6%, P = .017). Conclusion: A cortical rim-supported stemless implant maintained proximally improved dynamic bone loading in variable bone densities compared to a press-fit short stem implant. Biomechanical time-zero implant micromotion in lower bone densities was comparable between short stem and stemless implants at rehabilitation load levels (220 N, 520 N), but with higher cyclic stability and reduced variability for stemmed implantation at daily peak loads (820 N).

The Subscapularis Healing Index: A New Scoring System for Predicting Subscapularis Healing After Arthroscopic Repair.

BACKGROUND: Previous research has emphasized the effect of prognostic factors on arthroscopic rotator cuff repair (ARCR) success, but a specific focus on subscapularis (SSC) tendon repair healing is lacking. PURPOSE: To identify prognostic factors for SSC healing after ARCR and develop the Subscapularis Healing Index (SSC-HI) by incorporating these factors. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This was a retrospective study using prospectively maintained data collected from patients with isolated or combined SSC tears who underwent ARCR between 2011 and 2021 at a single institution with a minimum 2-year follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and visual analog scale (VAS) pain scale. SSC tendon healing was evaluated via ultrasound at the final follow-up. Multivariate logistic regression analysis was performed to determine the factors affecting SSC healing, and based on these factors, the SSC-HI, which ranges from 0 to 15 points, was developed using odds ratios (ORs). RESULTS: Among 1018 ARCR patients, 931 met the inclusion criteria; 279 returned voluntarily for postoperative SSC ultrasound assessment. The overall healing failure rate was 10.8% (30/279). Risk factors for healing failure included female sex (P = .008; OR, 3.119), body mass index (BMI) ≥30 (P = .053; OR, 2.323), supraspinatus fatty infiltration ≥3 (P = .033; OR, 3.211), lower SSC fatty infiltration ≥2 (P = .037; OR, 3.608), and Lafosse classification ≥3 (P = .007; OR, 3.224). A 15-point scoring system comprised the following: 3 points for female sex, 2 points for BMI ≥30, 3 points for supraspinatus fatty infiltration ≥3, 4 points for lower SSC fatty infiltration ≥2, and 3 points for Lafosse classification ≥3. Patients with ≤4 points had a 4% healing failure rate, while those with ≥9 points had a 55% rate of healing failure. Patients with a healed SSC reported significantly higher ASES (healed SSC: ΔASES, 44.7; unhealed SSC: ΔASES, 29; P < .01) and SSV (healed SSC: ΔSSV, 52.9; unhealed SSC: ΔSSV, 27.5; P < .01) and lower VAS (healed SSC: ΔVAS, -4.2; unhealed SSC: ΔVAS, -3; P < .01) scores compared with those with an unhealed SSC. CONCLUSION: The SSC-HI scoring system integrates clinical and radiological factors to predict SSC healing after surgical repair. Successful SSC healing was found to be associated with enhanced functional outcomes, underscoring the clinical relevance of SSC healing prediction in the management of these tears.

Functional internal rotation is associated with subscapularis tendon healing and increased scapular tilt after Grammont style bony increased offset reverse shoulder arthroplasty with 155° humeral implant.

BACKGROUND: While forward flexion consistently improves after reverse shoulder arthroplasty (RSA), restoration of internal rotation behind the back (IR1) is much less predictable. This study aims to evaluate the role of the subscapularis tendon in restoration of IR and identify other factors that may influence IR such as anterior scapular tilt and postoperative passive internal rotation at 90° of abduction (IR2). The hypothesis was that IR1 is positively associated with both subscapularis healing, postoperative passive IR2, and anterior scapular tilt. METHODS: A retrospective review was performed on a consecutive series of Grammont style bony increased offset RSAs performed by a single surgeon between January 2014 and December 2015. Inclusion criteria were: (1) primary RSA for rotator cuff arthropathy, massive irreparable rotator cuff tear, or primary osteoarthritis with B2 glenoid morphology, (2) minimum of two years clinical follow-up, and (3) complete intraoperative repair of a repairable subscapularis tendon. The primary outcomes were postoperative return of IR1 compared to postoperative IR2, healing rate of subscapularis tendon, and scapular tilt. RESULTS: The cohort included 77 patients, aged 72.6 ± 7.0 years at index surgery and comprising 32 men (42%) and 45 women (58%). At a mean follow-up of 3.3 ± 1.0 years, ultrasound evaluation revealed a successful repair of the subscapularis in 41 patients (53%). Healed subscapularis repair was significantly associated with greater IR1 (85% vs. 53%, P = .031). A multivariate logistic regression revealed functional postoperative IR1 was independently associated with subscapularis healing (odds ratio [OR], 4.3; 95% confidence interval [CI] [1.1-20.2]; P = .046) as well as greater anterior tilt (OR, 1.2; 95% CI [1.1-1.5]; P = .008) and postoperative IR2 (OR, 1.09; 95% CI [1.05-1.14]; P < .001) but lower postoperative passive abduction (OR, 0.96; 95% CI [0.92-1.00], P = .045). The area under receiver operating characteristic curve obtained with the Youden index was 0.88 with a sensitivity of 81.8% and specificity of 90.6%. CONCLUSIONS: This study revealed that in a Grammont-type RSA, postoperative IR1 recovery is first associated with subscapularis tendon healing, followed by IR2 and finally the ability to tilt the scapula anteriorly. Better understanding of these factors preoperatively may provide greater insight on expected return of functional internal after RSA.

Determining minimal clinically important difference and patient-acceptable symptom state after arthroscopic isolated subscapularis repair.

Background: Minimal Clinically Important Difference (MCID) and Patient-Acceptable Symptomatic State (PASS) have emerged as patient-based treatment assessments. However, these have not been investigated in patients undergoing arthroscopic isolated subscapularis repair (AISR). The primary purpose of this study was to determine the MCID and PASS for commonly used patient-reported outcomes in individuals who underwent AISR. The secondary purpose was to assess potential associations between preoperative and intraoperative patient characteristics and the MCID and PASS. Methods: A retrospective analysis was conducted on prospectively collected data for patients who underwent primary AISR between 2011 and 2021 at a single institution, with minimum 2-year postoperative follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and Visual Analog Scale (VAS) pain scale. The MCID was determined using the distribution-based method, while PASS was evaluated using area under the curve analysis. To investigate the relationship between preoperative variables and the achievement of MCID and PASS thresholds, Pearson and Spearman coefficient analyses were employed for continuous and noncontinuous variables, respectively. Results: A total of 77 patients with a mean follow-up of 58.1 months were included in the study. The calculated MCID values for VAS pain, ASES, and SSV were 1.2, 10.2, and 13.2, respectively. The PASS values for VAS pain, ASES, and SSV were 2.1, 68.8, and 68, respectively. There was no significant correlation between tear characteristics and the likelihood of achieving a MCID or PASS. Female sex, worker's compensation status, baseline VAS pain score, and baseline ASES score, exhibited weak negative correlations for achieving PASS for VAS pain and ASES. Conclusion: This study defined the MCID and PASS values for commonly used outcome measures at short-term follow-up in patients undergoing AISR. Tear characteristics do not appear to impact the ability to achieve a MCID or PASS after AISR. Female sex, worker's compensation claim, and low baseline functional scores have weak negative correlations with the achievement of PASS for VAS pain and ASES scores.

The subcoracoid distance is correlated with pain and internal rotation after reverse shoulder arthroplasty.

Background: A proposed etiology of anterior shoulder pain and limited internal rotation after reverse shoulder arthroplasty (RSA) is impingement of the humeral component on the coracoid or conjoint tendon. The primary goal of this study was to investigate radiographic surrogates for potential coracoid or conjoint tendon impingement and their relationship to postoperative pain and internal rotation after RSA. Methods: A retrospective review of a clinical registry was performed to identify patients with (1) primary RSA, (2) minimum 2-year clinical follow-up, and (3) satisfactory postoperative axillary lateral radiographs. The primary radiographic measurement of interest was the subcoracoid distance (SCD), defined as the distance between the posterior aspect of the coracoid and the anterior glenosphere. Additional measurements were as follows: anterior glenosphere overhang, posterior glenosphere overhang, native glenoid width, lateralization of glenosphere relative to the coracoid tip, lateralization shoulder angle, and distalization shoulder angle. The primary clinical outcome of interest was the 2-year postoperative Visual Analog Scale score. Secondary outcomes were (1) internal rotation (IR) defined by spinal level (IRspine), (2) IR at 90 degrees of abduction, (3) American Shoulder and Elbow Surgeons score, (4) forward flexion, and (5) external rotation at 0 degrees of abduction. Linear regression analyses were used to evaluate the relationship of the various radiographic measures on the clinical outcomes of interest. Results: Two hundred seventeen patients were included. There was a statistically significant relationship between the SCD and Visual Analog Scale scores: B = -0.497, P = .047. There was a statistically significant relationship between the SCD and IRspine: B = -1.667, P < .001. Metallic lateralization was also positively associated with improving IRspine; increasing body mass index was negatively associated. There was a statistically significant relationship between the SCD and IR at 90 degrees of abduction: B = 5.844, P = .034. Conclusion: For RSA with a 135° neck shaft angle and lateralized glenoid, the postoperative SCD has a significant association with pain and IR. Decreasing SCD was associated with increased pain and decreased IR, indicating that coracoid or conjoint tendon impingement may be an important and potentially under-recognized etiology of pain and decreased IR following RSA. Further investigations aimed toward identifying a critical SCD to improve pain and IR may allow surgeons to preoperatively plan component position to improve clinical outcomes after RSA.

Rates of subacromial notching are low following reverse shoulder arthroplasty with a 135° inlay humeral component and a lateralized glenoid.

Background: Lateralization in reverse shoulder arthroplasty (RSA) decreases bony impingement and improves rotational range of motion, but has been theorized to increase the risk of subacromial notching (SaN). The purpose of this study was to evaluate the presence of SaN following RSA and its relationship with lateralization with a 135° inlay humeral component. The secondary purpose was to assess the association of SaN with functional outcomes. Methods: A retrospective review was performed from a multicenter prospectively collected database on patients who underwent primary RSA from 2015 to 2021. All RSAs were performed with a 135° inlay humeral component. SaN was defined as bony erosion with sclerotic margins on the undersurface of the acromion on final follow-up radiographs not present preoperatively. Postoperative implant positioning (inclination, distalization, and lateralization) were evaluated on minimum 1-year postoperative radiographs. Regression analyses were performed on implant and clinical variables to assess for risk factors. A separate analysis was performed to determine the association of SaN with clinical outcomes. Results: SaN was identified in 13 out of 442 shoulders (2.9%). Age, sex, body mass index, smoking status, diabetes mellitus, arm dominance had no relationship with SaN. Neither glenoid sided lateralization nor humeral offset were associated with SaN risk. Other implant characteristics such as distalization, glenosphere size, and postoperative inclination did not influence SaN risk. The presence of SaN did not affect patient-reported outcomes (American Shoulder and Elbow Surgeons: P = .357, Visual Analog Scale: P = .210) or range of motion. Conclusion: The rate of SaN is low and not associated with glenoid or humeral prosthetic lateralization when using a 135° inlay humeral component. When SaN occurs, it is not associated with functional outcomes or range of motion at short-term follow-up.

Are Lower Passive Anterior Elevation and External Rotation at 6 Weeks Postoperatively Associated With Healing of Isolated Arthroscopic Supraspinatus Repairs?

BACKGROUND: Despite advancements in surgical technique, failure of tendon healing remains a common problem after arthroscopic rotator cuff repair (ARCR). PURPOSE/HYPOTHESIS: The purpose of this study was to examine the relationship between range of motion (ROM) recovery and healing after ARCR. It was hypothesized that an early loss of ROM would be associated with tendon healing. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: This was a retrospective comparative study of primary ARCR of isolated full-thickness supraspinatus (SSN) tendon tears. Cases were retrieved from a prospective rotator cuff repair database and divided into 2 groups based on healing (healed/nonhealed). A standardized clinical evaluation was performed before and at 6 weeks, 3 months, and 6 months after surgery. Collected data included passive and active ROM, visual analog scale for pain, and Constant score. Healing was assessed by ultrasound at 6 months. RESULTS: Of 1397 eligible ARCRs, 1207 were included. The healing rate was 86.7%. Age was higher in the nonhealed group (57.8 ± 7.9 years vs 61.6 ± 8.8 years; P < .001). Patients with healed repairs had a larger decrease in passive anterior elevation (AE) from the preoperative to the 6-week postoperative visit (-31°± 28° vs -18°± 26°; P < .001), followed by a more substantial increase throughout the remaining follow-up period (32°± 23° vs 18°± 21°; P < .001). At 6 months postoperatively, there was no difference in AE between groups (159°± 17° vs 161°± 14°; P > .999). External rotation elbow at side (ER1) and internal rotation hand in the back (IR1) followed similar courses of recovery. Passive and active ROM had a strong positive correlation at each follow-up. Age (odds ratio [OR], 1.79; 95% CI, 1.45-2.23; P < .001) and 6-week passive AE (OR, 1.33; 95% CI, 1.20-1.48; P < .001) and ER1 (OR, 1.15; 95% CI, 1.03-1.29; P = .017) were predictors for nonhealing. CONCLUSION: Lower passive AE and ER1 at 6 weeks postoperatively and younger age are associated with healing after ARCR of isolated SSN tendon tears. At 6 months postoperatively, there were no differences in ROM, regardless of tendon healing.

Editorial Commentary: Massive Rotator Cuff Tears Benefit From Arthroscopic Repair Regardless of Advanced Goutallier or Hamada Changes.

Massive rotator cuff tears are a challenge to treat, with options available from arthroscopic rotator cuff repair to reverse shoulder arthroplasty. Arthroscopic repair may still be an option even in the setting of advanced Goutallier changes and Hamada grades and regardless of healing. As the lifetime risk of revision for a 55-year-old patient having a reverse shoulder arthroplasty is approximately 1 in 3, arthroscopic surgical management of massive rotator cuff tears should not be discounted. An individualized approach should consider the patient's radiographs (severity of arthritis), function (i.e., acute vs chronic pseudoparalysis), and goals (overhead strength vs pain relief). Younger patients with less arthritis, acute pseudoparalysis, and a focus on pain relief could benefit from arthroscopic treatment.

Posteroinferior glenosphere positioning is associated with improved range of motion following reverse shoulder arthroplasty with a 135° inlay humeral component and lateralized glenoid.

BACKGROUND: Optimal glenosphere positioning in a lateralized reverse shoulder arthroplasty (RSA) to maximize functional outcomes has yet to be clearly defined. Center of rotation (COR) measurements have largely relied on anteroposterior radiographs, which allow assessment of lateralization and inferior position, but ignore scapular Y radiographs, which may provide an assessment of the posterior and inferior position relative to the acromion. The purpose of this study was to evaluate the COR in the sagittal plane and assess the effect of glenosphere positioning with functional outcomes using a 135° inlay stem with a lateralized glenoid. METHODS: A retrospective review was performed on a prospectively maintained multicenter database on patients who underwent primary RSA from 2015 to 2021 with a 135° inlay stem. The COR was measured on minimum 2-year postoperative sagittal plain radiographs using a best-fit circle fit method. A best-fit circle was made on the glenosphere and the center was marked. From there, 4 measurements were made: (1) center to the inner cortex of the coracoid, (2) center to the inner cortex of the anterior acromion, (3) center to the inner cortex of the middle acromion, and (4) center to the inner cortex of the posterior acromion. Regression analysis was performed to evaluate any association between the position of the COR relative to bony landmarks with functional outcomes. RESULTS: A total of 136 RSAs met the study criteria. There was no relation with any of the distances with outcome scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, visual analog scale). In regard to range of motion (ROM), each distance had an effect on at least 1 parameter. The COR to coracoid distance had the broadest association with ROM, with improvements in forward flexion (FF), external rotation (ER0), and internal rotation with the arm at 90° (IR90) (P < .001, P = .031, and P < .001, respectively). The COR to coracoid distance was also the only distance to affect the final FF and IR90. For every 1-mm increase in this distance, there was a 1.8° increase in FF and 1.5° increase in IR90 (ß = 1.78, 95% confidence interval [CI] 0.85-2.72, P < .001, and ß = 1.53, 95% CI 0.65-2.41, P < .001; respectively). CONCLUSION: Evaluation of the COR following RSA in the sagittal plane suggests that a posteroinferior glenosphere position may improve ROM when using a 135° inlay humeral component and a lateralized glenoid.

Reverse shoulder arthroplasty for massive rotator cuff tears without glenohumeral arthritis can improve clinical outcomes despite history of prior rotator cuff repair: A systematic review.

IMPORTANCE: Reverse shoulder arthroplasty (RSA) is often used to surgically address massive irreparable rotator cuff tears (MIRCT) without arthritis. The impact of prior attempted rotator cuff repair (RCR) on outcomes is unclear. OBJECTIVE: The purpose of this systematic review was to compare functional outcomes, range of motion, and complications in patients with a MIRCT without arthritis who underwent RSA as a primary procedure versus after prior RCR. EVIDENCE REVIEW: A systematic review was performed on RSA for a MIRCT. The search was conducted from February to March of 2022 using the MEDLINE database. Patient-reported outcome measures (PROs), range of motion (ROM), and complications were extracted. These outcomes were weighted and analysed based on whether the reverse was performed as the primary procedure or following a prior RCR. FINDINGS: Seven studies were included in the analysis, consisting of 343 cases in the primary RSA group and 95 cases in the prior RCR group, with a mean follow-up of 40.8 months. There were no demographic differences between cohorts. Postoperative PROs and ROM were comparable between groups, although the prior RCR group had a higher maximal percentage of improvement (MPI%) for the Constant-Murley Score and Simple Shoulder Test. There was a higher risk for complications (relative risk [RR] 6.26) and revisions (RR 3.91) in the prior RCR group. The most common complications were acromial stress fractures and prosthetic dislocation. CONCLUSION AND RELEVANCE: Patients undergoing RSA for MIRCT following a prior RCR have functional outcomes that are largely comparable to those who have a primary RSA, but they may be at higher risk of complications and revision. LEVEL OF EVIDENCE: IV.