Does Functional Bracing of the Unstable Shoulder Improve Return to Play in Scholastic Athletes? Returning the Unstable Shoulder to Play.

BACKGROUND: Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. HYPOTHESIS: The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. RESULTS: There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes (P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) (P = 0.47). CONCLUSION: This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. CLINICAL RELEVANCE: The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.

The Nonoperative Instability Severity Index Score (NISIS): A Simple Tool to Guide Operative Versus Nonoperative Treatment of the Unstable Shoulder.

BACKGROUND: The management of the adolescent athlete after initial shoulder instability remains controversial. HYPOTHESIS: Individual risk factors in athletes with shoulder instability who are managed nonoperatively can be integrated into a scoring system that can predict successful return to sport. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 57 scholastic athletes with primary anterior shoulder instability who were managed nonoperatively were reviewed. Success was defined as a return to index sport at the same level and playing at least 1 subsequent season without missed time as a result of the shoulder. Patient-specific risk factors were individually evaluated, and odds ratios were calculated. A 10-point Nonoperative Injury Severity Index Score (NISIS) incorporated the risk factors for failure. This score was then retrospectively applied with regression analysis and a chi-square analysis to determine the overall optimal score that predicted failure of nonoperative management. RESULTS: In total, 6 risk factors for failure were included in the NISIS: age (>15 years), bone loss, type of instability, type of sport (contact vs noncontact), male sex, and arm dominance. Overall, 79% of patients treated nonoperatively were able to successfully return to sport. Nearly all (97%) low-risk patients (NISIS <7) successfully returned to sport, while only 59% of high-risk patients returned to sport, a relative risk of 12.2 (P = 0.001). High-risk patients with unipolar bone loss successfully returned (100%), but 67% of high-risk patients with bipolar bone loss failed. CONCLUSION: The NISIS is a simple and effective clinical tool to determine successful nonoperative management following anterior shoulder instability and may be helpful in guiding decision making when presented with the unstable shoulder in the scholastic athlete.

Subscapularis Repair Is Unnecessary After Lateralized Reverse Shoulder Arthroplasty.

BACKGROUND: Controversy exists as to whether the subscapularis should be repaired after reverse shoulder arthroplasty. The purpose of the present study was to evaluate the utility of repairing the subscapularis after reverse shoulder arthroplasty with regard to complications, objective findings, and patient-reported outcome measures. METHODS: We retrospectively reviewed the records for 99 patients who had undergone a lateralized reverse shoulder arthroplasty with (n = 58) or without (n = 41) subscapularis repair. Outcomes were compared with the Single Assessment Numeric Evaluation (SANE), Penn shoulder score (PSS), Veterans RAND (VR)-12, and American Shoulder and Elbow Surgeons (ASES) score at a minimum of 2 years of follow-up. Demographics, range of motion, and complications were also compared. A 1-way analysis of variance was performed to determine differences in performance and outcome scores, and a chi-square analysis was performed to compare the frequency of complications between groups. RESULTS: There were no significant differences between the repair and no-repair groups in terms of SANE, PSS, ASES, or VR-12 scores. There also were no significant differences between the 2 groups in terms of postoperative ranges of forward elevation (128° versus 123°; p = 0.44) and external rotation (33° versus 29°; p = 0.29), the dislocation rate (5% versus 2%; p = 0.49), or the overall complication rate (9% versus 5%; p = 0.47). CONCLUSIONS: The results of the present study suggest that repair of the subscapularis tendon after lateralized reverse shoulder arthroplasty may not be necessary. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes of suprascapular nerve decompression: a systematic review.

BACKGROUND: Suprascapular neuropathy is an uncommon clinical diagnosis. Although there have been a number of case series reporting on this pathologic process, to date there has been no systematic review of these studies. This study aimed to synthesize the literature on suprascapular neuropathy with regard to clinical outcomes. The secondary objective was to detail the diagnosis and treatment of suprascapular neuropathy and any associated complications. METHODS: A systematic review was performed to identify studies that reported the results or clinical outcomes of suprascapular nerve decompression. The searches were performed using MEDLINE through PubMed and Cochrane Database of Systematic Reviews. RESULTS: Twenty-one studies comprising 275 patients and 276 shoulders met inclusion criteria. The mean age was 41.9 years, and mean follow-up was 32.5 months. The most common symptom was deep, posterior shoulder pain (97.8%), with a mean duration of symptoms before decompression of 19.0 months; 94% of patients underwent electrodiagnostic testing before decompression, and 85% of patients had results consistent with suprascapular neuropathy. The most common outcome reported was the visual analog scale score, followed by the Constant-Murley score. The mean postoperative Constant-Murley score obtained was 89% of ideal maximum. Ninety-two percent of athletes were able to return to sport. Only 2 (0.74%) complications were reported in the included studies. CONCLUSIONS: Surgical decompression in the setting of suprascapular neuropathy leads to satisfactory outcomes as evidenced by the patient-reported outcomes and return to sport rate. Furthermore, the rate of complications appears to be low.

The incidence and effect of fatty atrophy, positive tangent sign, and rotator cuff tears on outcomes after total shoulder arthroplasty.

BACKGROUND: Treatment choices for total shoulder arthroplasty (TSA) in the absence of full-thickness rotator cuff tears (RCTs) are not clearly defined in current literature. This study investigated the prevalence and effect of preoperative partial-thickness RCTs and muscular degenerative changes on postoperative outcomes after TSA. METHODS: Medical records and magnetic resonance imaging studies were reviewed for patients who underwent TSA for primary glenohumeral osteoarthritis with minimum 2-year follow-up to determine preoperative tear classification, Goutallier grade, and supraspinatus tangent sign. Postoperative pain on the visual analog scale, range of motion, and patient outcomes scores were obtained to correlate preoperative RCT status, Goutallier grading, tangent sign, and postoperative outcomes. Patients with full-thickness RCT on preoperative magnetic resonance imaging were excluded. RESULTS: Forty-five patients met all inclusion criteria (average age, 65 ± 10 years; average follow-up, 43 months). Of the patients undergoing TSA, 40% had a significant (>50% thickness) partial RCT. Grade 3 to 4 Goutallier changes were noted in 22% of all patients, and 13% demonstrated grade 3 to 4 changes in the context of no tear. Positive tangent sign was present in 7% of all patients. The preoperative Goutallier grade of the infraspinatus was significantly negatively correlated with postoperative forward elevation (P = .02) and external rotation (P = .05), but rotator cuff pathology, including tear status, Goutallier grade, and the presence of a tangent sign, did not correlate with postoperative functional outcome scores. CONCLUSIONS: Even in the absence of a full-thickness RCT, rotator cuff atrophy, fatty infiltration, and partial thickness tearing are common findings. Although postoperative range of motion is correlated to Goutallier changes of the infraspinatus, rotator cuff pathology is not correlated to outcomes after TSA; therefore, one may proceed with TSA without concern of their effect on postoperative outcomes.

Liposomal bupivacaine versus indwelling interscalene nerve block for postoperative pain control in shoulder arthroplasty: a prospective randomized controlled trial.

BACKGROUND: Pain management strategies following shoulder arthroplasty vary significantly. Liposomal bupivacaine (LB) is an extended-release delivery of a phospholipid bilayer encapsulating bupivacaine that can result in drug delivery up to 72 hours. Prior studies in lower extremity surgery demonstrated efficacy of LB in comparison to a single-shot peripheral nerve block; however, no study has investigated LB in a total shoulder arthroplasty population. Therefore, this study compared LB vs. an indwelling interscalene nerve block (IINB). METHODS: This is a prospective, randomized study of 83 consecutive shoulder arthroplasty patients; 36 patients received LB and a "bridge" of 30 mL of 0.5% bupivacaine, and 47 patients received an IINB. Postoperative visual analog scale pain levels, opiate consumption measured with oral morphine equivalents, length of hospital stay, and postoperative complications were recorded. Continuous variables were compared using an analysis of variance with significance set at P < .05. RESULTS: Visual analog scale pain scores were statistically higher in the LB cohort immediately postoperatively in the postanesthesia care unit (7.25 vs. 1.91; P = .000) as well as for the remainder of postoperative day 0 (4.99 vs. 3.20; P = .005) but not for the remainder of admission. Opiate consumption was significantly higher among the LB cohort in the postanesthesia care unit (31.79 vs. 7.47; P = .000), on postoperative day 0 (32.64 vs. 15.04; P = .000), and for the total hospital admission (189.50 vs. 91.70, P = .000). Complication numbers and length of stay were not statistically different. CONCLUSION: Use of an IINB provides superior pain management in the immediate postoperative setting as demonstrated by decreased narcotic medication consumption and lower subjective pain scores.

Resilience correlates with outcomes after total shoulder arthroplasty.

BACKGROUND: Resilience, characterized by an ability to bounce back or recover from stress, is increasingly recognized as a psychometric property affecting many outcomes' domains including quality of life, suicide risk in active-duty military personnel, and recovery in cancer patients. This study examines the correlation between resilience, as measured by the Brief Resilience Scale (BRS), and traditional outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA). METHODS: Seventy patients undergoing primary anatomic TSA were followed up for a minimum of 2 years (mean, 30 ± 3 months). Patients were stratified into groups a priori, based on deviation from the mean of the BRS score, into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients, and outcome scores were calculated for each group. RESULTS: Postoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (r = 0.41-0.44, P < .004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, P = .05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; P = .03). CONCLUSIONS: Resilience is a major predictor of postoperative outcomes after TSA. Patients who are classified as having LR have outcome scores that are 30 to 40 points lower on traditional outcome scales than patients with HR.

Preparedness of orthopaedic surgeons for modern battlefield surgery.

Over 220 U.S. Army orthopaedic surgeons have deployed during the Global War on Terrorism (GWOT). This study documents the orthopaedic procedures performed during the GWOT and identifies training that prepared surgeons for deployment. It reveals deficiencies in surgeons' preparedness and intends to improve predeployment training. All surgeons deployed during the GWOT from 2001 to 2007 were surveyed. Questions fit 4 general categories: deployment demographics, medical and surgical experiences, predeployment preparation, and self-perceived preparedness during deployment. Response rate was 70%. Surgeons averaged 138 adult operative cases and 26 pediatric cases per deployment. All surgeons performed irrigation and debridement, 94% external fixation, 93% amputations, 89% arthrotomies, 86% open reduction and internal fixation, and 76% soft-tissue coverage procedures. Residency and fellowship contributed most to surgeon preparedness for deployment. Surgeons generally reported high levels of preparedness, but nearly 1 in 6 reported low levels of medical, surgical and physical preparedness. More reported low levels of mental preparedness. Soft-tissue coverage was the most frequently reported surgical deficiency. This study documents the number and types of orthopaedic procedures performed during the GWOT and identifies the self-perceived preparedness deficiencies of surgeons in a combat environment. Improvements in predeployment training are needed to better prepare surgeons for managing battlefield causalities.

Comparison of the split stacked versus the split achilles allograft for dual femoral tunnel posterior cruciate ligament reconstruction.

BACKGROUND: Cadaveric testing has shown that double-bundle reconstruction better replicates the native anatomy of the posterior cruciate ligament. With the current trend toward allograft Achilles posterior cruciate ligament reconstructions, the need to determine a graft configuration with the highest tensile and pull-out strength has become paramount. HYPOTHESIS: The split stacked Achilles allograft construct provides greater graft material to traverse the notch and provides increased load to failure at the tibial point of fixation compared with a standard monoblock Achilles allograft construct. STUDY DESIGN: Controlled laboratory study. METHODS: Eight matched pairs of Achilles allograft tendons were secured to 8 matched pairs of fresh-frozen human cadaveric tibiae. Group 1 consisted of single-block grafts (n = 8), and group 2 included the split stacked grafts (n = 8). The cross-sectional area of each graft's 2 collagenous bundles was measured with a micrometer. The graft constructs were pulled to ultimate failure at a rate of 50 mm/min on a materials testing machine. RESULTS: The mean cross-sectional area of the group 2 split stacked grafts (76.6 +/- 3.1 mm(2)) was significantly greater than that of the group 1 single-block grafts (48.2 +/- 3.0 mm(2); P =.00006). The maximum load to failure of the group 2 construct was significantly greater (1383 +/- 102 N) than that of the group 1 single-block configuration (1020 +/- 136 N; P =.01). CONCLUSION: These results indicate that the novel split stacked configuration of an Achilles tendon allograft provides a greater cross-sectional area of graft material across the joint as well as a significant increase in the overall load to failure strength compared with a standard monoblock Achilles allograft construct. CLINICAL RELEVANCE: The split stacked Achilles graft is an efficient method for using the entire allograft. With maintenance and use of all collagen fibers, the split stacked Achilles construct provides essentially 2 grafts in 1 while only using a single tibial tunnel.

Tobramycin-impregnated calcium sulfate prevents infection in contaminated wounds.

Open fractures often are associated with increased rates of infection and nonunion, multiple surgical procedures, and delayed return to preinjury activity. Antimicrobial bone graft substitutes used as an alternative to antibiotic cement beads and/or delayed autologous bone grafting may provide a useful adjunct in patients with open fractures. A stable, unicortical defect was created and contaminated with 30 microL of 5 x 10 colony-forming units/mL of Staphylococcus aureus in the proximal tibial metaphysis of Spanish goats. The negative control group received no treatment, the carrier group received synthetic bone graft alone, the positive control group received tobramycin antibiotic cement, and the treatment group received tobramycin antimicrobial synthetic bone graft (calcium sulfate). After a 3-week evaluation period, intraosseous microbiologic specimens were obtained. The Staphylococcus aureus contaminant was recovered in 11 of 12 animals (mean = 6.9 x 10 colony-forming units/g marrow) in the negative control group and in all animals (mean = 2.2 x 10 colony-forming units/g marrow) in the carrier group. Bacteria were not found in the antibiotic-treated groups. The tobramycin-impregnated calcium sulfate was effective in preventing infection in a contaminated defect. It could be beneficial in reducing the number of surgeries and recovery time because it is bioabsorbable and osteoconductive.