Rotator cuff repair: Sleep disturbance significantly improves after arthroscopic tendon repair.

PURPOSE: The aim of this study was to quantify sleep quality and define its evolution in patients treated for rotator cuff tears (RCTs) with arthroscopic rotator cuff repair (ARCR) and to understand its correlation with patients' depression and anxiety. METHODS: The patients were part of the 'ARCR_Pred cohort study', a prospective multicentre cohort of ARCR patients. INCLUSION CRITERIA: adult, RCT diagnosed by magnetic resonance imaging, treated by primary ARCR. EXCLUSION CRITERIA: irreparable tears, revision operations, open or mini-open reconstructions, pregnancy. Subjective sleep quality (prevalence and level of disturbance) was analysed. Psychological characteristics (PROMIS Sf questionnaire) and functional outcomes (Constant and Murley Score and Oxford Shoulder Score) were investigated. A gender-based analysis was performed as well. Patients were evaluated before the operation and prospectively at 6 and 12 months. RESULTS: Of the 973 patients, 611 (62.8%) were men, with the mean age being 57.3 ± 9.4 years (range, 21-84). A high prevalence of sleep disturbances was found before ARCR (88.4%), with 59% of the patients complaining of disturbance every night. Sleep disturbances progressively improved at 6 (37.2%) and 12 months (22.0%). Also, nocturnal pain (frequency of night disturbed by pain) progressively improved from 94.3% to 62.4% and then 37.9%. For depression and anxiety, a statistically significant difference (p < 0.05) was retrieved among every group (undisturbed, occasionally and always disturbed) at all follow-ups. On the other hand, the post-op improvement led to a decrease in anxiety and depression levels passing from 50.1 and 51.4 points at baseline to 45.0 and 45.4 at 12 months, respectively. Women had statistically worse sleep quality at 6 and 12 months (41% vs. 36% and 27% vs. 19%, respectively) (p < 0.05). CONCLUSIONS: RCTs cause a high prevalence of sleep disturbance and nocturnal pain, which progressively resolves after an arthroscopic tendon repair. Women have a higher risk than men of presenting disturbed sleep quality. LEVEL OF EVIDENCE: Level III, prognostic cohort study.

Return to sports after reverse shoulder arthroplasty-the Swiss perspective.

PURPOSE: This patient survey evaluated the return to previous sports activities in Swiss patients up to five years after reverse shoulder arthroplasty (RSA). METHODS: We screened our local shoulder arthroplasty registry for patients registered with a unilateral RSA due to rotator cuff deficiency between May 2010 and May 2015. Revision cases and patients already known as unwilling or unable to complete a German language questionnaire were excluded. Eligible patients received a paper questionnaire asking about their past and current sports activities, return time point and level of activity. RESULTS: Of 305 patients, 89% responded at a mean post-operative follow-up of 2.9 years (SD 1.1). The respondents had a mean age of 77.1 years (SD 7.8) and included 62% females. The overall rate of patients returning to a previous sports activity was 77%. Sixty-one percent (166/271) participated in regular sports activities before the onset of their shoulder disorders. After RSA, 47% (127/271) participated in at least one sport type with the most frequent activities including hiking (66), swimming (53), cycling (45) and callisthenics (43). Most patients carried out their main sports activity after surgery with a moderate level of intensity (83%) and between one to three times per week (69%). Forty-two percent of the respondents indicated that returning to sports was among their key demands after RSA. CONCLUSIONS: Returning to previous sports activities is an important expectation of RSA patients, and the majority do. Patient expectations of post-operative sports activity need to be addressed when planning RSA.

A three-dimensional comparative study on the scapulohumeral relationship in normal and osteoarthritic shoulders.

BACKGROUND: Eccentric loading due to humeral translation is associated with worse clinical outcomes in hemiarthroplasty and total shoulder arthroplasty. The purpose of this study was to evaluate the 3-dimensional relationship of the humeral head to the scapula (scapulohumeral relationship) in nonpathologic shoulders and in shoulders with primary osteoarthritis. MATERIALS AND METHODS: Three-dimensional reconstructions of computed tomography scans of 151 nonpathologic shoulders (control group) and 110 shoulders with primary glenohumeral arthritis (OA group) were analyzed by measuring the anterior-posterior, inferior-superior, and medial-lateral position of the humeral head in relation to the scapula. Shoulders were classified as centered (type A) or posteriorly subluxed (type B) according to the Walch classification of glenoid morphology. Reproducibility and differences in scapulohumeral relationship were statistically analyzed. RESULTS: The scapulohumeral relationship could be determined reliably: the intraclass correlation coefficient ranged between 0.780 and 0.978; the typical error of measurement ranged between 2.4% and 5.0%. Both type A and type B shoulders showed significant posterior translation of the humeral head (P <.001). Type B shoulders had significantly more posterior translation than type A shoulders (P <.001). A tendency of inferior translation was noted, although with only marginal statistical significance (P = .051). In each morphology class, a medial deviation of the humeral head, representing a reduced glenohumeral distance, was measured (P <.001). CONCLUSIONS: The main characteristics of primary glenohumeral osteoarthritis are posterior humeral head translation relative to the scapula, reduced glenohumeral distance, and a tendency toward inferior humeral head translation in both type A and type B shoulders.

Accuracy of the glenohumeral subluxation index in nonpathologic shoulders.

BACKGROUND: Correction of posterior humeral subluxation, measured by the humeral subluxation index (HSI) according to Walch, is necessary in total shoulder arthroplasty to prevent early loosening. The 3-dimensional (3D) measurement of the shoulder is becoming well accepted and common practice as it overcomes positional errors to which 2-dimensional (2D) glenohumeral measurements are prone. The first objective was to describe the HSI in a nonpathologic population with the 2D HSI according to Walch and a newly described 3D HSI method. The second objective was to compare both measuring methods with each other. METHODS: In 151 nonpathologic shoulders, the 2D HSI was measured on the midaxial computed tomography scan cut of the scapula. The 3D HSI, based on the native glenoid plane, was defined as [formula in text], in which X is the projection of the center of the humeral head to the anteroposterior axis of the glenoid fossa and R is the radius of the humeral head. Both measuring methods were compared with each other. Correlation was determined. Interobserver and intraobserver reliability of the 3D HSI was measured. RESULTS: The mean 3D HSI (51.5% ± 2.7%) was significantly (P < .001) more posterior than the mean 2D HSI (48.7% ± 5.2%), with a mean difference of 2.9% ± 5.6%. No correlation was found between the 2D and 3D HSI. The interobserver and intraobserver reliability was excellent. CONCLUSION: The 2D HSI seems to underestimate the humeral subluxation compared with a 3D reliable equivalent.

Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation.

BACKGROUND: The objective of this study was to systematically review and quantitatively synthesize the data on recurrence rates after shoulder immobilization in internal versus external rotation in first-time, traumatic shoulder dislocations. MATERIALS AND METHODS: We performed a systematic search of the keywords "(((external rotation) OR internal rotation) AND immobilization) AND shoulder" in the online databases PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library. Random-effects models were used to calculate the cumulatively pooled risk ratios (RRs) of recurrent shoulder dislocations. All analyses were also stratified by age. RESULTS: We included 5 studies with a total of 471 patients (230 internal rotation and 241 external rotation) published between 2001 and 2011 in English. The pooled random-effects RR for recurrence of shoulder dislocations at all ages was 0.74 (95% confidence interval [CI], 0.44-1.27; P = .278). The RR was 0.70 (95% CI, 0.38 to 1.29; P = .250) for patients aged 30 years or younger and 0.78 (95% CI, 0.32 to 1.88; P = .579) for those aged older than 30 years. CONCLUSION: The current best evidence does not support a relative effectiveness of immobilization in external rotation compared with internal rotation to avoid recurrent shoulder dislocations in patients with traumatic anterior shoulder dislocations.

The effect of simulated scapular winging on glenohumeral joint translations.

HYPOTHESIS: In this study, we aim to test whether scapular winging results in a significant change in glenohumeral translation in the initial phase of the throwing motion. METHODS: Six shoulders underwent an abbreviated throwing motion (ATM) from late cocking to the end of acceleration by use of a validated robotic system. The intact specimens were tested to establish a baseline. The position of the scapula was then affected to simulate scapular winging by placing a cylindrical wedge under the inferior angle of the scapula, and the ATM was performed again. For both conditions, the average glenohumeral translations and scapular rotations were plotted over time to calculate the area under the curve, as a representative of the overall glenohumeral translations and scapular rotations observed during the ATM. RESULTS: Throughout the motion, the winged scapulae showed, on average, 7.7° more upward rotation, 1.6° more internal rotation, and 5.3° more anterior tipping as compared with the baseline. The scapular position relative to the hanging arm was significantly different between the baseline and scapular winging conditions in all arm positions, except for maximal external rotation and the neutral position. Comparing the area under the curve at baseline and with scapular winging indicated that scapular winging significantly increased anterior translation of the glenohumeral joint whereas translation in the superior/inferior and medial/lateral directions did not result in a change in translation. DISCUSSION: These results may suggest a more important role of abnormalities in scapular position in predisposing throwing athletes to shoulder injuries of the anterior capsulolabral structures and consecutive glenohumeral instability.

Thinking outside the glenohumeral box: Hierarchical shape variation of the periarticular anatomy of the scapula using statistical shape modeling.

Variation in the shape of the glenoid and periarticular anatomy of the scapula has been associated with shoulder pathology. The goal of this study was to identify the modes of shape variation of periarticular scapular anatomy in relation to the glenoid in nonpathologic shoulders. Computed tomography scans of 31 cadaveric scapulae, verified to be free of pathology, were three-dimensionally reconstructed. Statistical shape modeling and principal component analysis identified the modes of shape variation across the population. Corresponding linear and angular measurements quantified the morphometric variance identified by the modes. Linear measures were normalized to the radius of the inferior glenoid to account for differences in the scaling of the bones. Five modes captured 89.7% of total shape variation of the glenoid and periarticular anatomy. Apart from size differences (mode 1: 33.0%), acromial anatomy accounted for the largest variation (mode 2: 32.0%). Further modes described variation in glenoid inclination (mode 3: 11.8%), coracoid orientation and size (mode 4: 9.0%), and variation in coracoacromial (CA) morphology (mode 5: 3.1%). The average scapula had a mean acromial tilt of 49 ± 7°, scapular spine angle of 61 ± 6°, the glenoid inclination of 84 ± 4°, coracoid deviation angle of 26 ± 4°, coracoid length of 3.7 ± 0.3 glenoid radii, and a CA base length of 5.6 ± 0.5 radii. In this study, the identified shape modes explain almost all of the variance in scapular anatomy. The acromion exhibited the highest variance of all periarticular anatomic structures of the scapula in relation to the glenoid, which may play a role in many shoulder pathologies.

Platelet-Rich Plasma Reduces Retear Rates After Arthroscopic Repair of Small- and Medium-Sized Rotator Cuff Tears but Is Not Cost-Effective.

BACKGROUND: It has been suggested that platelet-rich plasma (PRP) improves healing after arthroscopic rotator cuff repair. The current literature provides ample but inconsistent data on this topic. PURPOSE: To systematically review the current in vivo evidence for the use of platelet concentrates (PRP) in the arthroscopic treatment of rotator cuff tears to assess effectiveness, safety, and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: Published evidence from controlled, human trials of rotator cuff repair augmented with platelet concentrates was systematically gathered, and data on retear rates were extracted. Mathematical and clinical heterogeneity was evaluated, and fixed-effect meta-analysis was performed to calculate the risk ratio (RR) of retears and the number needed to treat (NNT). Subgroup analyses were made for small/medium tears (n = 404) and large/massive tears (n = 374). Cost-effectiveness was assessed using data from this meta-analysis and using cost data from the literature, including extensive sensitivity analyses, to calculate the incremental cost-effectiveness ratio (ICER). RESULTS: Thirteen studies published between 2010 and 2014 were identified for analysis. The RR for retear for all patients was 0.87 (95% CI, 0.67-1.12; P = .286). For small- and medium-sized tears (<3 cm), the RR for retear was 0.60 (95% CI, 0.37-0.97), consistent with a significant difference in favor of PRP use (P = .038). This translated into an NNT of 14 (95% CI, 7-125). However, at an ICER of US$127,893 per quality-adjusted life year gained, assuming a 5% revision rate, the use of PRP was not cost-effective for small- and medium-sized tears. CONCLUSION: In large tears, even with double-row repair, the beneficial effects of PRP alone are insufficient to compensate the progressed tissue damage. The study data suggest that PRP may promote healing of small- and medium-sized tears to reduce retear rates. However, despite the substantial biological effect, at current cost, the use of PRP is not cost-effective in arthroscopic repair of small- and medium-sized tears.

Bulk effect of the deltoid muscle on the glenohumeral joint.

BACKGROUND: There remains controversy on the role of the deltoid on glenohumeral translations during basic and pitching motions. We thus studied the passive effect of the deltoid on the deltoid glenohumeral joint center (GHJC). METHODS: Six shoulders were tested using an automated mechanical system. A baseline motion pattern of the intact specimen was contrasted with glenohumeral translation after removal of the deltoid. Each condition was evaluated in abduction (ABD) and an abbreviated throwing motion (ATM) using retro-reflective, bone-embedded markers. The absolute trajectory and the area under the curve (AUC) for each motion were calculated and glenohumeral kinematics with respect to the GH translation were compared. RESULTS: The removal of the deltoid resulted in significant changes of the GH translation. During 30-60° of ABD, it resulted in a superior and more anterior GH translation, while in the 60-90° segment in a more inferior and medial GH translation. During 90-120°, the GH translation was medialized. In the pitching motion from maximum external rotation to 90° of external rotation (ER), the removal of the deltoid resulted in a more superior, anterior and lateral GH translation. Thus limits anterior translation in the abduction-external rotation position. In the remaining segments (90-80° and 80-45° of ER), it resulted in a lateralization of the GH translation. CONCLUSIONS: Modelling the throwing shoulder, the deltoid has a significant influence on glenohumeral motion. Athletes with deltoid dysfunction and limited range of motion are at risk for injury due to the resulting change in their throwing mechanics.

The effect of supraspinatus tears on glenohumeral translations in passive pitching motion.

BACKGROUND: Supraspinatus tears are common in pitchers. However, the effect of these tears on glenohumeral (GH) mechanics is incompletely understood. PURPOSE/HYPOTHESIS: To describe the effect of supraspinatus tears and repairs on GH kinematics during an abbreviated throwing motion using the intact shoulder girdle. The hypothesis was that supraspinatus tears would lead to an increase of GH translation in the coronal plane and supraspinatus repairs would restore GH kinematics. STUDY DESIGN: Controlled laboratory study. METHODS: Six shoulders from 3 fresh-frozen cadavers were tested in a novel 7 degrees of freedom robotic testing system. Torsos were mounted and the wrist was pinned to an actuator mounted on an upper frame. After the deltoid was removed, the shoulders were studied during an abbreviated throwing motion (ATM) from maximum external rotation to the midcoronal plane to establish a baseline. The ATM was repeated after creation of a 1-cm supraspinatus tear, after creation of a 3-cm supraspinatus tear, and after repair with a transosseous equivalent (TOE) technique. Retroreflective bone markers and high-speed infrared cameras were used to measure GH kinematics and calculate the center of rotation of the GH joint (CORGH) instantaneously. RESULTS: The 1- and 3-cm supraspinatus tears did not significantly alter GH translation. The TOE repair shifted the CORGH posteriorly, as evidenced by a significant decrease in the overall GH translation in all 3 planes (P = .003, .019, and .026, for x-y, y-z, and x-z planes, respectively). CONCLUSION: In contrast to a TOE repair of the supraspinatus tendon, isolated supraspinatus tears did not perturb GH kinematics in this cadaveric model of the throwing shoulder. CLINICAL RELEVANCE: In throwing athletes, treatment of rotator cuff tears should be addressed with caution to avoid an unintended alteration in GH kinematics due to overtightening of the tendon.