Preoperative handgrip strength can predict early postoperative shoulder function in patients undergoing arthroscopic rotator cuff repair.

BACKGROUND: Rotator cuff tears (RCTs) are a common musculoskeletal disorder, and arthroscopic rotator cuff repair (ARCR) is widely performed for tendon repair. Handgrip strength correlates with rotator cuff function; however, whether preoperative grip strength can predict functional outcomes in patients undergoing ARCR remains unknown. This study aimed to investigate the correlation between preoperative grip strength and postoperative shoulder function following ARCR. METHODS: A total of 52 patients with full-thickness repairable RCTs were prospectively enrolled. Baseline parameters, namely patient characteristics and intraoperative findings, were included for analysis. Postoperative shoulder functional outcomes were assessed using the Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) questionnaire and Constant-Murley scores (CMSs). Patients were followed up and evaluated at three and six months after ARCR. The effects of baseline parameters on postoperative outcomes were measured using generalized estimating equations. RESULTS: At three and six months postoperatively, all clinical outcomes evaluated exhibited significant improvement from baseline following ARCR. Within 6 months postoperatively, higher preoperative grip strength was significantly correlated with higher CMSs (ß = 0.470, p = 0.022), whereas increased numbers of total suture anchors were significantly correlated with decreased CMSs (ß = - 4.361, p = 0.03). Higher body mass index was significantly correlated with higher postoperative QDASH scores (ß = 1.561, p = 0.03) during follow-up. CONCLUSIONS: Higher baseline grip strength predicts more favorable postoperative shoulder function following ARCR. A preoperative grip strength test in orthopedic clinics may serve as a predictor for postoperative shoulder functional recovery in patients undergoing ARCR.

Two-Year Retrospective Patient-Reported Outcomes Following Superior Capsular Reconstruction.

PURPOSE: The purpose of this study was to evaluate the short-term patient-reported outcomes of superior capsular reconstruction (SCR) and identify factors contributing to the success or failure of the procedure at 2 years. METHODS: A retrospective review was performed on data prospectively collected from the Surgical Outcomes System database. Patient-reported outcomes (PROMs) including American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, visual analog scale for pain, and Veterans RAND 12-Item Health Survey (VR-12) were evaluated at a minimum of 2 years postoperatively and reported using a minimal clinically important difference (MCID) and the percent of maximal possible improvement (MPI). In addition, preoperative and intraoperative variables were evaluated in patients with and without a postoperative improvement in ASES and SANE scores meeting the threshold of MCID. RESULTS: Two-year follow-up data were available for 350 patients. Statistically significant improvements were noted in all PROMs at 2-year follow-up. In total, 240 patients (68.8%) achieved an MCID improvement of >17.5 in ASES score, and 185 patients (52.9%) achieved an MCID of >29.8 improvement in the SANE score. Primary SCRs were associated with a higher MPI in the ASES score (60.1% ± 39.8% vs 40.4% ± 47.9%; P = .025) and VR-12 physical score (14.0% ± 13.8% vs 8.0% ± 14.7%; P = .028) compared to revision repairs. Only diabetes was identified as a predictor of SANE score improvement (64.5% vs 62.2%; P = .041). CONCLUSIONS: SCR is associated with improvement in patient-reported outcomes at short-term follow-up, with 53% to 69% of patients achieving an improvement considered to meet the MCID. Greater improvement is expected when SCR is performed as a primary procedure rather than as a revision procedure for failed rotator cuff repair. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A Tensionable Suture-based Cerclage Is an Alternative to Stainless Steel Cerclage Fixation for Stabilization of a Humeral Osteotomy During Shoulder Arthroplasty.

INTRODUCTION: Fixation of periprosthetic humeral fractures is most commonly obtained with steel-based wires or cables; however, disadvantages with these constructs are numerous. Suture-based cerclages offer the advantage of easy handling, less radiographic interference, and risk of metallosis, as well as decreased risk of cutting into the soft humeral bone. Therefore, the purpose of this study was to compare a suture-based cerclage to a stainless steel wire cerclage (SSWC) for stabilization of the humerus during shoulder arthroplasty. METHODS: In part I of the study, SSWC fixation was compared with single-looped tape cerclage and a double-looped tape cerclage (DLTC) fixation. In part II, a subsidence test was performed on 12 cadaveric humeri. After an osteotomy, the humeri were secured with either a SSWC or DLTC. Subsequently, a metal wedge was introduced into the humerus to simulate the stem of a shoulder arthroplasty. RESULTS: In part I, load to 2-mm displacement was significantly higher for the DLTC construct compared with the SSWC construct (2,401 ± 483 N versus 750 ± 33 N; P < 0.0001). Load to failure was 935 ± 143 N with the SSWC, 1,737 ± 113 N with the single-looped tape cerclage, and 4,360 ± 463 N with the DLTC constructs, and all differences were statistically significant (P < 0.05). In part II, load at 20-mm subsidence was higher for the DLTC (320 ± 274 N) compared with the SSWC (247 ± 137 N), but no significant difference was observed (P > 0.05). However, gap displacement at 20 mm subsidence was significantly lower with the DLTC construct (0.33 ± 0.31 mm versus 0.77 ± 0.23 mm; P = 0.009). Load to failure was higher with the DLTC construct compared with the SSWC construct (4,447 ± 2,325 N versus 1,880 ± 1,089 N; P = 0.032), but the final gap displacement did not differ significantly (DLTC 5.23 ± 6.63 mm versus SSWC 6.03 ± 8.82 mm; P > 0.05). DISCUSSION: A DLTC has higher load to failure and trends toward lower gap displacement compared with a SSWC. The DLTC construct may therefore be a viable alternative for fixation of periprosthetic fractures or osteotomies of the humeral shaft during shoulder arthroplasty.

The Effect of Glenohumeral Fixation Angle on Deltoid Function During Superior Capsule Reconstruction: A Biomechanical Investigation.

PURPOSE: To evaluate the effect of dermal allograft fixation at different angles of glenohumeral abduction on deltoid forces during superior capsule reconstruction (SCR). METHODS: Fifteen cadaveric specimens were tested using a dynamic shoulder simulator. Following testing in the native state, shoulders underwent SCR in 2 of 5 possible fixation angles; 0°, 15°, 30°, 45°, or 60° of glenohumeral abduction, allowing for 6 specimens per group. Angles were measured radiographically with the glenoid fixed perpendicular to the floor. Maximum mean deltoid abduction force was compared among 5 separate conditions within each angle group: (1) native shoulder, (2) complete supraspinatus (SSP) and superior capsule tear, (3) SCR alone, (4) SCR with posterior margin sutured, and (5) SCR with anterior and posterior margins sutured. RESULTS: SSP tears significantly increased the maximum deltoid forces for all 5 fixation angles compared with the native state (P < .05). Specimens repaired at 0°, 30°, and 45° were unable to restore deltoid forces compared with the native state in any condition (P < .05). SCR at 15° with anterior and posterior margin convergence showed similar abduction forces compared with the native state (P = .19). When fixed at 60° abduction, SCR alone significantly reduced deltoid forces compared to SSP (Δ143N, P < .001) and native (Δ48N, P < .001). No significant differences were found between the 3 repair subtypes (SCR ± anterior/posterior margin repair) in the 60° group. CONCLUSIONS: SCR with anterior and posterior margin convergence tensioned at 15° of glenohumeral abduction showed similar deltoid abduction force requirements compared with the native state, whereas graft fixation in 60° significantly reduced deltoid force in all SCR conditions. CLINICAL RELEVANCE: Increased graft tension with a greater abduction angle may provide greater functional outcome by placing less load on the deltoid. In contrast, graft fixation in lower abduction angles may require additional margin convergence to reproduce native forces.

Biomechanical Effect of Superior Capsule Reconstruction Using a 3-mm and 6-mm Thick Acellular Dermal Allograft in a Dynamic Shoulder Model.

PURPOSE: To biomechanically compare the effect of superior capsule reconstruction (SCR) using a 3- and 6-mm thick acellular dermal allograft for the treatment of irreparable rotator cuff tears. METHODS: Eight fresh-frozen cadaveric shoulders were tested using a dynamic shoulder model. Maximum abduction angle (MAA), glenohumeral superior translation (ghST), subacromial peak contact pressure (sPCP), and cumulative deltoid force (cDF) were compared among 4 conditions: (1) intact shoulder, (2) simulated irreparable rotator cuff tear (RCT), (3) SCR using a 3-mm-thick acellular dermal allograft, (4) SCR using a 6-mm-thick acellular dermal allograft. RESULTS: Compared with the intact state, simulated irreparable RCTs significantly decreased MAA (P < .001), while significantly increasing ghST (P = .001), sPCP (P < .001), and cDF (P < .001). SCR with a 3-mm-thick graft significantly increased MAA (P = .01) and decreased ghST (P = .01) compared with the RCT state, however, showed similar sPCP and cDF. Compared with the torn state, SCR with a 6-mm-thick graft significantly increased MAA (P < .001) and significantly decreased ghST (P < .001), sPCP (P < .001), and cDF (P = .001). Using a 6-mm-thick graft demonstrated similar MAA, ghST, sPCP, and cDF compared with the intact state. When comparing the 3-mm to the 6-mm thick graft, significant differences were found in ghST (P = .03), sPCP (P < .001), and cDF (P = .02). CONCLUSIONS: SCR with a 6-mm-thick acellular dermal allograft better restored normal glenohumeral joint position and forces compared with a 3-mm-thick graft for the treatment of irreparable RCTs. CLINICAL RELEVANCE: Graft thickness may affect the clinical success following SCR with commercially available dermal allografts. Using a thicker (>3 mm) graft was able to biomechanically better restore native glenohumeral joint properties.

The Histology of a Healed Superior Capsular Reconstruction Dermal Allograft: A Case Report.

Acellular human dermal allograft commonly is used in the surgical treatment of complex rotator cuff tears, but little information is known about the biological fate of these grafts in human subjects. In this case report, the authors describe a patient who presented with a radiographically healed acellular human dermal allograft superior capsular reconstruction but had humeral head avascular necrosis. The healed superior capsular reconstruction, including graft-bone interfaces, was explanted after 7 months and sent for histologic analysis. A successful biological reconstruction of the superior capsule was found. The graft demonstrated gross and microscopic incorporation with the host, including a tendon-like structure, aligned collagen fibers, fibroblast-like cells, and no clear graft-host distinction. Cellular infiltration ranged from 5% to 14% (central graft) to 65% to 92% (sutured attachment points). Neovascularization and active graft remodeling were confirmed histologically. LEVEL OF EVIDENCE: V, case report.

Does Arthroscopic Simulation Training Improve Triangulation and Probing Skills? A Randomized Controlled Trial✰.

OBJECTIVE: To determine the effectiveness of simulator training on basic arthroscopic skills utilizing a novel, low-cost arthroscopic triangulation training system. DESIGN: A randomized controlled trial of subjects without prior arthroscopy training was conducted, with participants randomized to receive either a fixed protocol of simulation training on a triangulation simulation model (30 minutes of training for 4 consecutive days), or no training. On Days 1 and 5, all participants were evaluated on 3 simulated arthroscopic tasks by an independent observer. Variables analyzed included how many times portals were changed, the time it took to complete the tasks, and the task completion rate. SETTING: Arthrex Inc., Naples, FL. PARTICIPANTS: Thirty-six participants (92% male, average 28 ± 5 years) with no prior arthroscopy training were randomized into 2 groups, with 17 in the training group (T) and 19 in the no-training group (NT). RESULTS: On Day 1, there was no difference in rate of task completion between the T group and NT groups (41% versus 53%, p = 0.52). On Day 5, significantly more participants in the T group completed all tasks compared to the NT group (100% versus 63%, p = 0.008). Participants in the T group had significantly improved task completion times on Day 5 versus Day 1 (p < 0.05). Participants in the NT group had a significantly improved task completion time for Task 1 on Day 5 versus Day 1 (p = 0.037); no differences were found for Tasks 2 or 3. On Day 5, participants in the T group required significantly fewer portal changes compared to the NT group (2.35 ± 2.29 versus 6.95 ± 8.55, p = 0.039). CONCLUSIONS: Simulation training on a simple, low-cost arthroscopic triangulation training system resulted in an overall improvement in arthroscopic probing and triangulation skills within 1 week of training, with significantly decreased task completion times and increased efficiency of movement.

Triple-Loaded Suture Anchors Versus a Knotless Rip Stop Construct in a Single-Row Rotator Cuff Repair Model.

PURPOSE: To compare the biomechanical properties of single-row repair with triple-loaded (TL) anchor repair versus a knotless rip stop (KRS) repair in a rotator cuff repair model. METHODS: Rotator cuff tears were created in 8 cadaveric matched-pair specimens and repaired with a TL anchor or KRS construct. In the TL construct, anchors were placed in the greater tuberosity and then all suture limbs were passed through the rotator cuff as simple sutures and tied. In the KRS construct, a 2-mm suture tape was passed through the tendon in an inverted mattress fashion, and a free suture was passed medial to the suture tape to create a rip-stop. Then, the suture tape and free suture were secured with knotless anchors. Displacement was observed with video tracking after cyclic loading, and specimens were loaded to failure. RESULTS: The mean load to failure was 438 ± 59 N in TL anchor repairs compared with 457 ± 110 N in KRS repairs (P = .582). The mean displacement with cyclic loading was 3.8 ± 1.6 mm in TL anchor repairs versus 4.3 ± 1.8 mm in the KRS group (P = .297). Mode of failure was consistent in both groups, with 6 of 8 failures in the TL anchor group and 7 of 8 failures in KRS group occurring from anchor pullout. CONCLUSIONS: There is no statistical difference in load to failure and cyclic loading between TL anchor and KRS single-row repair techniques. CLINICAL RELEVANCE: KRS repair technique may be an alternative method of repairing full-thickness supraspinatus tendon tears with a single-row construct.

Lack of level I evidence on how to prevent infection after elective shoulder surgery.

PURPOSE: Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery. METHODS: An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery. RESULTS: Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over povodine and iodine to prep the skin at the time of surgery. Level II-IV evidence was found for other infection prevention methods such as intravenous antibiotic prophylaxis. CONCLUSION: There are many risk factors associated with developing an infection after elective shoulder surgery. Many preventive measures have been described which may decrease the risk of infection; however, most lack a high level evidence to support them. The findings of this systematic review are clinically relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden. As surgeons the goal should be to prevent infections to avoid the morbidity for patients and the increased cost for society. LEVEL OF EVIDENCE: IV systematic review of literature.

Preliminary Results of Arthroscopic Superior Capsule Reconstruction with Dermal Allograft.

PURPOSE: The purpose of this study was to evaluate the short-term outcomes of arthroscopic superior capsule reconstruction (SCR) with dermal allograft for the treatment of irreparable massive rotator cuff tears (MRCTs). METHODS: A multicenter study was performed on patients undergoing arthroscopic SCR for irreparable MRCTs. The minimum follow-up was 1 year. Range of motion and functional outcome according to visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV) score were assessed preoperatively and at final follow-up. Radiographs were used to evaluate the acromiohumeral interval (AHI). RESULTS: Fifty-nine patients with a mean age of 62.0 years had a minimum follow-up of 1 year. Twenty-five patients (42.4%) had a prior rotator cuff repair. Forward flexion improved from 130° preoperative to 158° postoperative, and external rotation improved from 36° to 45°, respectively (P < .001). Compared with preoperative values, the VAS decreased from 5.8 to 1.7, the ASES score improved from 43.6 to 77.5, and the SSV score improved from 35.0 to 76.3 (P < .001). The AHI was 6.6 mm at baseline and improved to 7.6 mm at 2 weeks postoperatively but decreased to 6.7 mm at final follow-up. Based on postoperative magnetic resonance imaging, 45% (9 of 20) of the grafts demonstrated complete healing. Forty-six (74.6%) cases were considered a success. Eleven patients (18.6%) underwent a revision procedure including 7 reverse shoulder arthroplasties. CONCLUSIONS: Arthroscopic SCR using dermal allograft provides a successful outcome in approximately 70% of cases in an initial experience. The preliminary results are encouraging in this difficult to manage patient population, but precise indications are important and graft healing is low in our initial experience. LEVEL OF EVIDENCE: Level IV, case series.

The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study.

BACKGROUND: The aim of this study was to find reliable anatomic landmarks of the normal acromioclavicular joint (ACJ) that could enable the precise evaluation of the horizontal displacement of the clavicle after dislocation. The hypothesis was that the anterior borders of the acromion and the clavicle are always aligned in intact ACJs. MATERIALS AND METHODS: In 30 cadaveric specimens, the anterior and posterior borders of the ACJ's articular facets and the most prominent anterior and posterior bony landmarks of the acromion and the clavicle were identified. The anterior and posterior overhang of the acromion and the clavicle was measured in relation to the borders of the articular facets. Therefore, the possible anterior and posterior alignment of the ACJ was evaluated. RESULTS: Anteriorly, only 18 ACJs (60%) were aligned whereas 7 (24%) had major overhang of the acromion and 3 (10%) had major overhang of the clavicle. Similarly, 18 cases (60%) were posteriorly aligned, whereas 6 (20%) had major clavicular overhang and 4 (14%) had major overhang of the acromion. In 78% of these cases, the ACJ was aligned as well anteriorly as posteriorly (P < .001). Finally, the larger the width of the acromion (P = .032) or the clavicle (P = .049), the better the posterior joint alignment. CONCLUSION: Our hypothesis was not verified. The acromion and clavicle are not perfectly aligned in a significant number of specimens with intact ACJs (40% of cases). The most reliable landmarks remain their articular facets.

Safety of Superior Labrum Anterior and Posterior (SLAP) Repair Posterior to Biceps Tendon Is Improved With a Percutaneous Approach.

We conducted a study to compare a standard anterosuperolateral (ASL) portal with a percutaneous Port of Wilmington (PW) portal for repair of superior labrum anterior and posterior (SLAP) tears. We hypothesized that anchors placed through the PW portal would be less likely to penetrate the glenoid or injure the suprascapular nerve (SSN). This study used 6 matched-pair cadaveric shoulders. Two anchors were arthroscopically placed posterior to the biceps, at 11 o'clock and 10 o'clock, to simulate a SLAP repair. One set of anchors was placed through an ASL portal and the other through a PW portal. Glenoid vault penetration and distance to SSN were noted. In the ASL portal group, 8 (66.7%) of 12 anchors violated the medial cortex of the glenoid; in the penetration cases, mean distance to SSN was 6.8 mm for 11 o'clock anchors and 4.8 mm for 10 o'clock anchors. In the PW portal group, 2 (16.7%) of 12 anchors violated the medial cortex of the glenoid; in the penetration cases, distance to SSN was 20 mm for the 11 o'clock anchor and 8 mm for the 10 o'clock anchor. The risk of glenoid vault penetration during repair of SLAP tears posterior to the biceps tendon is reduced when a percutaneous posterior approach is used for anchor placement. This approach also directs the anchor away from the SSN.

Quantitative and Computed Tomography Anatomic Analysis of Glenoid Fixation for Superior Capsule Reconstruction: A Cadaveric Study.

PURPOSE: To investigate glenoid fixation for superior capsule reconstruction (SCR) and evaluate anchor positions, intraosseous trajectories, and proximity to the suprascapular nerve (SSN) and glenoid fossa. The secondary purpose was to provide technical pearls and pitfalls for anchor insertion on the superior glenoid during SCR. METHODS: Three beath pins were arthroscopically inserted into 12 (n = 12) nonpaired human cadaveric shoulders through Neviaser, anterior, and posterior portals to simulate anchor placement on the superior glenoid during SCR. Computed tomography scans were performed to evaluate anchor positioning and insertion trajectories. Specimens were then dissected to delineate the anatomic relations of the beath pins to the SSN and glenoid fossa. RESULTS: The superior glenoid anchor position was a mean 15.0 ± 4.0 mm to the SSN and 6.5 ± 1.7 mm to the glenoid fossa. The posterior glenoid anchor position was a mean 11.8 ± 2.1 mm to the SSN and 2.9 ± 2.9 mm to the glenoid fossa. On average, the superior pin was placed at 12:30 ± 0:30 (left-sided glenoid clock face) and inserted at 19° ± 9° with respect to the sagittal plane of the glenoid, the anterior pin was placed at 11:00 ± 0:30 and inserted 40° ± 17° off the glenoid, and the posterior pin was placed at 3:00 ± 1:00 and inserted at 52° ± 12° off the glenoid. CONCLUSIONS: The results of the present cadaveric study showed that glenoid fixation was safe with respect to the SSN and delineated technical guidelines and trajectories for inserting 3 anchors into the glenoid. CLINICAL RELEVANCE: This study shows that 3 anchors can be inserted into the glenoid without a risk of SSN damage and delineates technical guidelines for anchor insertion.

Patient-Reported Outcomes of Knotted and Knotless Glenohumeral Labral Repairs Are Equivalent.

We conducted a study to compare the clinical results and operative times of knotted and knotless fixation of anterior and posterior glenohumeral labral repairs and superior labrum anterior to posterior (SLAP) repairs. We retrospectively evaluated data that had been prospectively collected from a Surgical Outcomes System database. Knotted and knotless techniques for 226 repairs (59 isolated anterior labral, 95 posterior labral, 72 SLAP) were compared on patient-reported outcome measures (PROMs), including American Shoulder and Elbow Surgeons (ASES) score, visual analog scale pain score, and Veterans RAND 12-Item Health Survey score, obtained before surgery and 6 months and 1 year after surgery. Operative time was recorded as well. One-year follow-up was available for all 226 repairs. There was no statistically difference in PROMs between knotted and knotless anterior labral or SLAP repairs at any point (P > .05). ASES scores were higher 6 months after surgery in the knotless group (88.6 vs 84.2; P = .022), but scores 1 year after surgery were the same (88.6 vs 89.8; P = .451). Operative time per anchor was shorter for knotless anterior labral repairs (26 vs 31 min; P = .02) and knotless posterior labral repairs (18 vs 21 min; P = .031) and trended shorter for knotless SLAP repairs (26 vs 37 min; P = .080). There is no difference in PROMs between knotted and knotless labral repairs. Operative times were shorter for anterior and posterior knotless anchors than for knotted anchors. Obtaining equivalent outcomes in less operative time may help decrease healthcare costs and minimize potential complications.

The Rotator Cuff and the Superior Capsule: Why We Need Both.

Tears of the rotator cuff are frequent. An estimated 250,000 to 500,000 repairs are performed annually in the United States. Rotator cuff repairs have been successful despite fatty infiltration and atrophy of the rotator cuff muscles. Although the emphasis in rotator cuff repair has historically focused on re-establishing the tendon attachment, there is growing interest in and understanding of the role of the superior capsule. The superior capsule is attached to the undersurface of the supraspinatus and infraspinatus muscle-tendon units, and it resists superior translation of the humeral head. Herein, we propose that it is the defect in the superior capsule that is the "essential lesion" in a superior rotator cuff tear, as opposed to the defect in the rotator cuff itself. We propose that rotator cuff repair must restore the normal capsular anatomy to provide normal biomechanics of the joint and thus a positive clinical outcome.

The Arthroscopic Superior Capsular Reconstruction.

In a subset of patients with rotator cuff tears, the glenohumeral joint has minimal degenerative changes and the rotator cuff tendon is either irreparable or very poor quality and unlikely to heal. Reverse shoulder arthroplasty (RSA) is often considered for these patients despite the lack of glenohumeral arthritis. However, due to the permanent destruction of the glenohumeral articular surfaces, complication rates, and concerns about implant longevity with RSA, we believe the superior capsular reconstruction (SCR) is a viable alternative. In this article, we describe our technique for the SCR.

Pseudoparalysis From a Massive Rotator Cuff Tear Is Reliably Reversed With an Arthroscopic Rotator Cuff Repair in Patients Without Preoperative Glenohumeral Arthritis.

BACKGROUND: Pseudoparalysis is defined as active forward flexion less than 90° with full passive motion. There is controversy about the ideal surgical management of a massive rotator cuff tear with pseudoparalysis. PURPOSE/HYPOTHESIS: The purpose of this study was to prospectively analyze the ability to reverse pseudoparalysis with an arthroscopic rotator cuff repair (ARCR). The hypothesis was that in the absence of substantial glenohumeral arthritis, preoperative fatty infiltration of grade 3 or higher and an acromiohumeral interval (AHI) of less than 7 mm would not prevent reversal of pseudoparalysis with an ARCR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A prospective multicenter study of ARCR performed for preoperative pseudoparalysis was conducted. The minimum follow-up was 1 year. The mean patient age was 63 years, and pseudoparalysis was present for a mean of 4.2 months preoperatively. Preoperative radiographic evaluation included plain film evaluation of the AHI and Hamada classification and MRI evaluation of fatty degeneration and rotator cuff retraction. Functional outcome was determined by the Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, visual analog scale (VAS), and subjective shoulder value (SSV). RESULTS: Of the 58 patients enrolled, 56 had at least 1 year of follow-up. Mean active forward flexion improved from 47° preoperatively to 159° postoperatively (P < .001). Statistically significant improvements were seen in the SST (from 2.8 preoperatively to 10.1 postoperatively), SSV (from 28 to 83), ASES Shoulder Score (from 37 to 88), and VAS (from 5.7 to 1.1) (P < .001). Pseudoparalysis was reversed in 53 of 56 patients (95%). There was no difference in the rate of reversal of pseudoparalysis between those patients with an AHI of less than 7 mm (88.2%) and those with an AHI of 7 mm or more (96.9%) (P =.289). Pseudoparalysis was reversed in all 8 of the patients with fatty degeneration of grade 3 or higher in 1 or more of the rotator cuff muscles. CONCLUSION: ARCR can lead to reversal of preoperative pseudoparalysis in patients with minimal preoperative glenohumeral arthritis. ARCR is a viable first line of treatment for patients with pseudoparalysis in the absence of advanced glenohumeral arthritis.

Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of outcomes, complications, and revision rate.

PURPOSE: The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation. METHODS: Seven surgeons pooled data on patients who underwent an arthroscopic biceps tenodesis at the articular margin by interference screw fixation. All patients had a minimum of 50 weeks' follow-up. Preoperative and postoperative patient data including visual analog scale scores (obtained by all surgeons), objective shoulder scores (Simple Shoulder Test and University of California, Los Angeles scores obtained by 2 and 4 surgeons, respectively), and need for revision surgery (obtained by all surgeons) were retrospectively analyzed, the results are reported, and statistical analysis was performed. RESULTS: After the application of our exclusion criteria, 1,083 patients were included in the analysis. The mean follow-up period was 136 weeks. The overall revision surgery rate for this group was 4.1% (44 of 1,083). Revision for biceps tenodesis-related issues was needed in only 4 cases (for a biceps tenodesis-related revision rate of 0.4%). Pain scores improved from 6.47 preoperatively to 1.08 postoperatively (P < .0001). University of California, Los Angeles scores improved from 14.9 preoperatively to 30.1 postoperatively (P < .0001), and Simple Shoulder Test scores improved from 2.7 preoperatively to 10.2 postoperatively (P < .0001). CONCLUSIONS: Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Associated lesions requiring additional surgical treatment in grade 3 acromioclavicular joint dislocations.

PURPOSE: To evaluate the incidence of associated pathologic shoulder lesions that were addressed surgically in grade 3 acromioclavicular joint (ACJ) dislocations, as well as to compare this incidence between younger and older patients and between acute and chronic cases. METHODS: In this multicenter nonrandomized retrospective study, 98 patients operated on for grade 3 ACJ dislocation underwent concomitant arthroscopic evaluation for the identification and treatment of any associated lesions. The type and treatment of associated lesions were collected in a central database and analyzed. We classified patients according to age (<45 years and ≥ 45 years) and according to the length of time between trauma and surgical treatment (≤ 30 days and ≥ 120 days), obtaining the following stratification: younger acute, older acute, younger chronic, and older chronic. RESULTS: Of the patients, 42 (42.8%) were diagnosed with at least 1 additional pathologic lesion, and 29 (29.5%) required a dedicated additional treatment. Rates of treatment on associated lesions were analyzed: younger versus older groups presented a significant difference, as did younger acute versus older acute groups; SLAP and posterior rotator cuff tear treatments represented 24 of the 35 additional surgeries (68.5%). CONCLUSIONS: The overall rate of associated pathologic lesions requiring additional surgical treatment in patients with ACJ dislocation was 29.5%. Patients aged 45 years or older had a greater risk of presenting with associated lesions that needed to be surgically addressed (odds ratio, 3.01). The overall rates of associated surgical lesions in acute versus chronic cases were not shown to be significantly different. LEVEL OF EVIDENCE: Level IV, prognostic case series.