Subscapularis Repair in Reverse Total Shoulder Arthroplasty: Differences in Outcomes Based on Preoperative Quality of Subscapularis Tendon.

Purpose: This study examines the influence of preoperative fatty infiltration (FI) of the subscapularis tendon (SBS) on outcomes following reverse total shoulder arthroplasty (rTSA) with SBS repair. Methods: A cohort of 161 rTSA patients with SBS repair, followed for a mean of 45.3 months, was divided into three groups based on FI: Group A (intact upper and lower portions, n = 85), Group B (intact lower portions, n = 44), and Group C (fatty infiltrated in both portions, n = 32). The mean age was 74.5 years (range: 65-95). Results: Preoperative FI displayed significant disparity among the groups: Group A (1.18 ± 0.60), Group B (2.95 ± 0.56), and Group C (4.0 ± 0.00) (p < .001). Group A exhibited a more positive trend in activities of daily living, particularly in toileting ability (81% in Group A, 68% in Group B, and 72% in Group C), although without statistical significance (p = 0.220). Complication rates varied: Group A had seven acromial fractures (8%), three cases of instability (3%), and six instances of scapular notching (7%). Group B experienced four acromial fractures (9%) and four cases of scapular notching (9%), while Group C had only one case of scapular notching (3%) (p = 0.733). Conclusion: In cases characterized by favorable preoperative SBS quality, there was an elevation in functional internal rotation (IR) post-surgery, accompanied by an increased incidence of postoperative complications. Hence, careful consideration is advised when determining the necessity for SBS repair. Level of Evidence: Level III, retrospective comparative study.

Does timing influence rehabilitation outcomes in arthroscopic rotator cuff repair with biceps rerouting? a prospective randomized study.

BACKGROUND: Arthroscopic rotator cuff repair with biceps rerouting (ABR) has emerged as a reliable option for treating large posterosuperior rotator cuff tears (RCTs). This study aims to compare functional and structural outcomes of early vs. delayed motion rehabilitation protocols following ABR. METHODS: A total of 101 patients with semirigid, large, posterosuperior RCTs undergoing ABR were randomized into 2 groups: group I (early motion) with 53 patients (34 females, 19 males) and group II (delayed motion) with 48 patients (31 females, 17 males). In group I, the mean age was 63.9 years (range, 46-79), and in group II, it was 65.4 years (range, 43-78). The mean follow-up periods for group I and group II were 16.2 and 15.5 months, respectively. Preoperative and postoperative assessments were conducted at 3, 6, and 12 months, with structural integrity assessed with magnetic resonance imaging at a minimum follow-up of 12 months. Statistical analyses were performed to compare outcomes between the 2 groups. RESULTS: Both groups demonstrated significant improvements in visual analog scale score (group I: 4.0-1.6, group II: 3.7-1.4, P = .501), University of California-Los Angeles shoulder score (group I: 21.5-31.4, group II: 22.4-30.6, P = .331), and acromiohumeral interval (group I: 8.2 mm-9.1 mm, group II: 8.6 mm-9.5 mm, P = .412), with no statistically or clinically meaningful differences. Active range of movements (ROM) were not significantly different between groups, except for active forward flexion at 3 months (group I: 140.1°, group II: 119.2°, P = .006), that was not shown to be translated clinically into differences in function or healing between the groups in this study. Notably, retear rates were similar between groups (group I: 22.6%, group II: 20.8%, P = .826). CONCLUSION: This study's findings reveal no clinically discernible differences in active range of motion at 1-year follow-up between patients who underwent ABR for semirigid, large, posterosuperior RCTs and were assigned to either early or delayed motion protocols. Notably, the early motion group demonstrated a plateau in maximum range of movement improvement as early as 3 months postsurgery. Based on these results, implementing an early motion protocol is recommended as an effective approach in the postoperative rehabilitation following ABR.

Outcomes of arthroscopic single-row repair alone vs. repair with human dermal allograft patch augmentation in patients with large to massive, posterosuperior rotator cuff tears: a retrospective comparative study.

BACKGROUND: Large to massive rotator cuff tears (RCTs) affect shoulder functions profoundly with unmanageable disability without intervention. The retear rates with arthroscopic rotator cuff repair (ARCR) in these patients are abysmal. Patch augmentation has been credited for preventing retears, improving functions by increasing the strength, and acting as a bioconductive scaffold. This study aimed to assess the retear rates and compare the clinical and radiological outcomes between the ARCR with and without acellular human dermal allograft (HDA) augmentation. METHODS: This is a retrospective comparative study among patients diagnosed with large to massive, posterosuperior RCTs, operated between January 2020 and December 2021, including 36 patients (group I) with and 131 patients (group II) without HDA augmentation, with a mean follow-up of 20 (range, 12-35) months. The average age was 64 (range, 49-80) and 66 (range, 41-81) years in groups I and II, respectively. In group I, there were 16 male and 20 female patients, whereas in group II, there were 58 male and 73 female patients. RESULTS: The visual analog scale score improved to 1.1 ± 1.7 in group I and 2.1 ± 1.7 in group II (P = .005). There was a greater improvement in the University of California, Los Angeles shoulder score to 30.1 ± 4.2 in group I compared with 23.2 ± 3.9 in group II (P = .046). Forward flexion (degrees) improved from a mean of 103.2 ± 18.6 to 138.9 ± 23.5 in group I and from 106.4 ± 21.3 to 127.0 ± 19.5 in group II (P = .004). The acromiohumeral interval (mm) measured in anteroposterior radiographs increased to 8.4 ± 1.8 in group I and 8.2 ± 2.0 in group II (P = .006). The satisfaction after the procedure was 4.4 ± 0.6 in group I and 3.1 ± 1.1 in group II (P = .044). The retear rate in the HDA-augmented group was 5.6% as compared with 29.1% in the nonaugmented group, which was statistically significant (P = .007). There were no complications or adverse tissue reactions against HDA seen in any patients. CONCLUSION: In patients with large to massive, posterosuperior RCTs, patch augmentation with acellular HDA significantly averted the retears after ARCR without any graft-related complications. The augmentation also resulted in improved shoulder function and greater range of motion compared with the nonaugmented group.

Anterior capsular reconstruction in irreparable subscapularis tear: human dermal allograft.

BACKGROUND: The irreparable subscapularis (SSc) tears pose an extremely difficult situation to manage, especially in the younger population. The anterior capsular reconstruction (ACR) with human dermal allograft (HDA) is an alternative to tendon transfer with sound biomechanical advantages and clinical outcomes. The purpose of this study was to evaluate the early clinical and radiologic outcomes of open ACR with HDA in patients with irreparable SSc tears. METHODS: Eighteen patients who had an open ACR with HDA for irreparable SSc tears between August 2020 and January 2022 were enrolled. There were 11 male and 7 female patients with a mean age of 63.7 years and a mean follow-up of 17 months (range, 12-28 months). The dominant side was affected in 10 patients. One of the 18 patients had reconstruction with single-layer HDA, 14 had double-layer HDA, and 3 had SSc augmentation over double-layer HDA. Clinical and radiologic outcomes were assessed and compared pre- and postoperatively. RESULTS: There was significant improvement in visual analog scale score from 6.6 ± 1.6 to 1.6 ± 1.5 (P < .001) and in the total University of California-Los Angeles shoulder score from 12.4 ± 4.3 to 29.0 ± 4.5 (P < .001). Forward flexion, abduction, and internal rotation (IR) increased by 28.6°, 32.5°, and 11.8°, respectively (P < .001). External rotation decreased by 6.4° (P = .020). There was notable improvement in IR strength (percentage of that of the opposite, normal side) from 66.0% ± 19.4% to 84.4% ± 22.3% (P = .008). The mean postoperative coracohumeral distance improved from 3.0 to 6.0 mm (P < .001), the anterior translation of the humeral head reduced from 1.5 to 0.5 mm (P = .210), and the acromiohumeral interval from 8.1 to 8.8 mm (P = .070). The patients' satisfaction at final follow-up was rated 4.1 of 5.0 (P < .001). Sixteen of 18 patients (88.9%) had the HDA healed at the glenoid and humeral side, and 2 (11.1%) had retear at the final follow-up. Among the 17 who had double-layer HDA, none showed any healing between the layers. CONCLUSION: This study showed that early significant and comprehensive improvement inclusive of pain relief, improvement in range of motion, IR strength, and reduction of anterosuperior translation was achievable by open ACR with HDA for irreparable SSc tear.

Rotator cuff repairs with all-suture tape anchors: no difference in outcomes between with or without all-suture tape anchors.

PURPOSE: This study aimed at comparing the outcomes of medium- to large-sized rotator cuff repairs performed using the suture bridge technique either with or without tape-like sutures, and single row techniques with conventional sutures. METHODS: A total of 135 eligible patients with medium to large rotator cuff tears were identified and analyzed retrospectively, from 2017 to 2019. Only repairs using all-suture anchors were included in the study. Patients were divided into the following three groups: single-row (SR) repair (N = 50), standard double-row suture bridge (DRSB) repair with conventional sutures (N = 35), and DRSB with tape-like sutures (N = 50). The average postoperative follow-up period was 26.3 ± 9.8 months (range, 18-37). RESULTS: DRSB with tapes had the highest re-tear rate of 16% (8/50), but there was no significant difference with the re-tear rates observed in SR (8%, 4/50) and DRSB with conventional sutures (11.4%, 4/35) (n.s.). DRSB with tapes demonstrated higher rate of type 2 re-tears (10%) compared to type 1 re-tears (6%), but the other two groups showed either similar or higher rates of type 1 re-tears compared to that of type 2. Post-operative functional scores of the three groups improved significantly (all p < 0.05), but the differences between the groups were not statistically significant. CONCLUSIONS: No clinical difference in functional outcomes and re-tear rates were observed in DRSB with tapes when compared with SR and DRSB using the conventional sutures. Tape-like DRSB suture which was expected to be superior by its biomechanical advantage was clinically non-superior to conventional DRSB suture. There were no significant differences in VAS scores and UCLA scores. LEVEL OF EVIDENCE: Level III.

Synovial Osteochondromatosis: Clinical Characteristics Unique to the Shoulder.

Background: Synovial osteochondromatosis (SOC) of the shoulder is a rare condition with unclear characteristics. This study evaluated the clinical features and postoperative functional outcomes of SOC of the shoulder that are distinct from SOC of other joints. Methods: The characteristics of 28 shoulders with SOC that underwent arthroscopy were retrospectively assessed. Ten shoulders (35.7%) had rotator cuff tears (RCTs) and underwent concomitant arthroscopic rotator cuff repair. The mean follow-up period was 83.6 months (range, 24-154 months). Demographic characteristics and loose bodies localized under arthroscopy were compared between cases with and without concomitant RCTs. Radiography, ultrasonography, or magnetic resonance imaging were performed preoperatively and postoperatively. Visual analog scale (VAS) scores for pain and satisfaction were evaluated for all cases, and functional scores were assessed in shoulders with concomitant RCTs. Results: The average age was 36.2 ± 15.6 years among patients without RCTs and 58.3 ± 7.2 years among patients with RCTs. Seven shoulders (7%) had osteoarthritis. Arthroscopy revealed loose bodies in multiple spaces, including the glenohumeral joint, subacromial (SA) space, and biceps tendon sheath. Overall, loose bodies were found in multiple spaces in 12 shoulders (42.9%). Loose bodies were found in the SA space only in 4 shoulders (22.2%) without RCTs and in 7 shoulders (70.0%) with RCTs. VAS for pain decreased significantly from 3.9 ± 2.3 to 1.1 ± 1.3 (p < 0.001). The functional scores increased significantly after arthroscopic management for patients with concurrent RCTs (all p < 0.05). Recurrence of SOC occurred in 3 of the 22 shoulders (13.6%) who underwent postoperative imaging, but no patient had a recurrent RCT. Conclusions: Pain relief and patient satisfaction were achieved via arthroscopic management. Unlike in other joints, loose bodies can occur simultaneously in several spaces in the shoulder, including the glenohumeral joint, SA space, and biceps tendon sheath. Early diagnosis of SOC of the SA space can help prevent osteoarthritis and RCT progression.

Long-term outcomes after humeral head replacement and total shoulder replacement for osteonecrosis of the humeral head: a mean follow-up of 8 years.

INTRODUCTION: The purpose of this study was to compare the outcomes and complications after humeral head replacement (HHR) and total shoulder replacement (TSR) in patients with osteonecrosis of the humeral head (ONHH). MATERIALS AND METHODS: Twenty-six patients who underwent shoulder replacement (13 HHRs and 13 TSRs) for nontraumatic ONHH were included. The mean follow-up period was 96.4 months. The visual analog scale (VAS) pain score, the University of California at Los Angeles (UCLA) score, the American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM) at the final follow-up evaluation were used for the assessment of clinical outcomes. RESULTS: The mean VAS pain score, UCLA score, and ASES score showed significant improvement from 6.3, 11.6, and 35.0 before surgery to 2.2, 28.9, and 82.6 at the final follow-up evaluation (all p < 0.001). No significant differences regarding all clinical scores and ROMs were observed between the HHR group and the TSR group, except that a greater abduction angle was observed in the HHR group compared with the TSR group (123.1° versus 96.9°, p = 0.014). Two patients in the TSR group underwent multiple reoperations due to periprosthetic joint infection. No revision surgeries were performed for glenoid erosion following HHR or aseptic glenoid loosening following TSR. CONCLUSIONS: The findings of this study showed satisfactory clinical and radiological outcomes with implant longevity for both HHR and TSR in patients with nontraumatic ONHH. The HHR group had a greater abduction angle compared with the TSR group.

Anteroposterior and Lateral Coverage of the Acromion: Prediction of the Rotator Cuff Tear and Tear Size.

Background: The aim of this study was to assess whether the anteroposterior coverage of the acromion reflecting acromial morphology affects the rotator cuff tear (RCT) and tear size, in addition to the lateral coverage. Methods: Medical records of 356 patients with RCTs, concentric osteoarthritis, and calcific tendinitis identified using three-dimensional computed tomography between January 2016 and December 2017 were retrospectively analyzed. The patients were divided into group A (those with RCTs) and group B (those with concentric osteoarthritis or calcific tendinitis). Subsequently, group A was subdivided into three categories according to the size of RCTs: small-to-medium, large, and massive. The lateral coverage was measured through the lateral acromial angle (LAA) and critical shoulder angle (CSA), whereas the anteroposterior coverage was measured via the acromial tilt (AT), acromiohumeral interval (AHI) in the sagittal view, and anteroposterior coverage index (APCI) as a new radiologic parameter. Results: Between groups A and B, CSA (34.5° ± 3.4° and 30.8° ± 3.4°, respectively), APCI (0.83 ± 0.10 and 0.75 ± 0.08, respectively), and AHI (6.3 ± 2.0 mm and 7.8 ± 1.8 mm, respectively) were significantly different (all p < 0.001), whereas LAA and AT did not show a significant difference between the groups (p = 0.089 and p = 0.665, respectively). The independent predictive radiologic parameters of the RCT were the CSA, APCI, and AHI (p < 0.001, p < 0.001, and p = 0.043, respectively); among these, the APCI showed the highest regression coefficient (odds ratio = 2.82). The parameters associated with the size of RCTs were CSA (p = 0.022) and AHI, of which AHI, in particular, had the most significant effect on both small-to-medium and large tears (all p < 0.001). Conclusions: Large CSA, high APCI, and low AHI were predictors of RCTs, with the APCI showing the strongest correlation. In addition to the large CSA, low AHI also correlated with the size of RCTs and affected the entire size groups. We suggest that both the lateral coverage and anteroposterior coverage of the acromion should be considered essential factors for predicting the presence of RCTs and tear size.

The scissors sign: a provocative test for detecting the leading-edge tear of subscapularis tendon: a diagnostic study.

BACKGROUND: Several physical examination tests and signs have been described to aid in the diagnosis of subscapularis (SSC) tear, but have limitations and variable sensitivity. This study aimed to introduce a novel test for detecting a leading-edge tear of the subscapularis (LETS), the most important tendinous portion of SSC. METHODS: A total of 233 patients who underwent arthroscopic repair for anterior and superior cuff tears between January 2018 to September 2019 were retrospectively reviewed. The provocative test we have coined as the "scissors sign" and the other related clinical tests (i.e., belly press, belly off, Napoleon, lift off, internal rotation lag, bear hug tests) were performed preoperatively. Whether the patient has a LETS or the complete tear of the SSC (CTS) was confirmed by arthroscopic findings. Sensitivity, specificity, and areas under the receiver operating characteristic curve were calculated for each test. RESULTS: In patients who had LETS with or without supraspinatus tear, the scissors sign showed the highest sensitivity (91.4%) with a specificity of 81.6%, positive predictive value (PPV) of 80.2%, and negative predictive value (NPV) of 92.1%. In patients with isolated LETS, the scissors sign also showed the highest sensitivity (90.3%) with a specificity of 81.6%, PPV of 57.1%, and NPV of 96.8%. The scissors sign for the complete tear of the subscapularis (CTS) with or without supraspinatus tear and the isolated CTS had a sensitivity of 73.1 and 75%, respectively. CONCLUSIONS: The scissors sign is a novel provocative test that can be helpful in the diagnosis of subscapularis tears, especially LETS, with its high sensitivity and diagnostic accuracy. In combination with other tests, the scissors sign will be a good screening tool.

Clinical and Radiologic Outcomes of Small Glenoid Baseplate in Reverse Total Shoulder Arthroplasty: A Prospective Multicenter Study.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiologic outcomes of reverse total shoulder arthroplasty (RTSA) using a small glenoid baseplate in patients with a small glenoid and to analyze the contributing factors to scapular notching. METHODS: A total of 71 RTSAs performed using a 25-mm baseplate were evaluated at a mean of 37.0 ± 3.3 months. Shoulder function was evaluated using American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE) for satisfaction, and active range of motion. Scapular neck angle (SNA), prosthesis-scapular neck angle (PSNA), peg glenoid rim distance (PGRD), and sphere bone overhang distance (SBOD) were measured to assess the effects on scapular notching. RESULTS: Shoulder function (ASES: 39.4 ± 13.8 preoperative vs. 76.2 ± 9.5 at last follow-up, p < 0.001), VAS for pain (6.1 ± 1.8 vs. 1.7 ± 1.4, p < 0.001), SANE for satisfaction (7.0 ± 11.8 vs. 83.4 ± 15.3, p < 0.001), and active forward flexion (115.6° ± 40.1° vs. 141.6° ± 17.2°, p < 0.001) were significantly improved. The mean diameter of the inferior glenoid circle was 26.0 ± 3.0 mm and the mean glenoid vault depth was 24.0 ± 4.5 mm. Scapular notching was found in 13 patients (18.3%) and acromial fracture in 2 patients (2.8%). There were no significant differences in preoperative SNA and PSNA at postoperative 3 years between patients with and without scapular notching (101.6° ± 10.5° and 110.8° ± 14.9° vs. 97.3° ± 13.3° and 104.9° ± 12.4°; p = 0.274 and p = 0.142, respectively). PGRD and SBOD were significantly different between patients with scapular notching and without scapular notching (24.8 ± 1.6 mm and 2.6 ± 0.5 mm vs. 21.9 ± 1.9 mm and 5.8 ± 1.9 mm; p < 0.001 and p < 0.001, respectively). CONCLUSIONS: RTSA using a 25-mm baseplate in a Korean population who had relatively small glenoids demonstrated low complication rates and significantly improved clinical outcomes. Scapular notching can be prevented by proper positioning of the baseplate and glenosphere overhang using size-matched glenoid baseplates.

Medialized vs. lateralized humeral implant in reverse total shoulder arthroplasty: the comparison of outcomes in pseudoparalysis with massive rotator cuff tear.

BACKGROUND: With the increasing use of lateralized humeral implants in reverse total shoulder arthroplasty (RTSA), it is still unclear whether this design will be as advantageous as the medialized humeral implants in the setting of pseudoparalysis (PP). METHODS: A total of 51 eligible RTSA cases for PP signs due to massive rotator cuff deficiency were selected for the retrospective review. Twenty-five patients were allocated to group L in which the isolated humeral side lateralization was performed (neck-shaft angle of 145°), and 26 patients were allocated to group M (neck-shaft angle of 155°). Pre- and postoperative radiologic measurements including critical shoulder angle, acromiohumeral distance (AHD), lateral humeral offset (LHO), and deltoid wrapping offset (DWO), as well as range of motion (ROM) and clinical outcome scores, were compared. The mean age was 71.0 ± 6.5 years for group L and 70.3 ± 7.0 years for group M, and the overall mean follow-up period was 49.0 ± 13.5 months (range, 25.7-68.9). RESULTS: The preoperative radiologic measurements were similar, but the postoperative LHO and DWO were significantly larger for group L, whereas the postoperative AHD was larger for group M compared with group L, with the values being 39.8 ± 9.7 mm and 33.6 ± 10.4 mm, respectively (P = .034). For the ROM, active forward elevation did improve significantly for both, starting preoperatively with the active ranges of 39° ± 19° (passively 153° ± 24°) for group L and 42° ± 18° (passively 156° ± 11°) for group M-the final postoperative active ranges being 142° ± 16° and 133° ± 33°, respectively, without significant difference between the groups (P = .426). The postoperative recovery of PP for group L was 100% (25 of 25), whereas for group M, it was 96.2% (25 of 26). The final visual analog scale (VAS) scores and University of California Los Angeles (UCLA) shoulder scores improved significantly for both groups, but the differences between the groups at the final assessments were insignificant. The 4 complications were periprosthetic fracture, acromial stress fracture, periprosthetic joint infection, and neuropraxia, all of which were in group M, and scapular notching with higher grades were more prevalent for group M (26.9%, 7 of 26). CONCLUSIONS: With RTSA, good outcomes and recovery were achieved in most cases of PP. The postoperative active elevation range and functional outcomes were not affected by medialization or lateralization of the humeral implant. Earlier recovery of motion was observed with the lateralized group, but no significant differences were seen in the final ROM between the groups.

Retracted Rotator Cuff Repairs Heal With Disorganized Fibrogenesis Without Affecting Biomechanical Properties: A Comparative Animal Model Study.

PURPOSE: To determine the differences in the scar tissue formation during the healing of the repaired retracted cuff tear from that of the nonretracted tear. METHODS: Eighteen right rabbit shoulders received a 1-cm transverse cuff incision over the footprint to simulate "nonretracted cuff tears" before the transosseous repairs (group A). A 1-cm tendinous portion was excised from 18 left shoulders to create defects to simulate "retracted cuff tears" before repairing the defects (group B). At week 12 postrepair, 20 and 16 shoulders underwent histologic and biomechanical analyses, respectively. Eight shoulders were used as a control group for biomechanical analyses. RESULTS: All specimens showed good healing and continuity of the repaired tendons. At low magnification, fibrous tissue firmly held the tendon-to-bone junctions in group A; however, all specimens in group B showed medially retracted tendons with fibrous tissue continuity between the tendon stumps and footprints. At medium magnification, more irregular collagen fiber orientation was observed in group B. Polarized light microscopy showed fibrous tissue continuity with medially retracted tendons in group B. When we quantified collagen fiber orientation using ImageJ software, group B had inferior grayscale measurements when compared with group A (P = .001). At week 12, no statistical differences existed in mean loads-to-failure at the repair sites between the groups (P = .783). CONCLUSIONS: In the nonretracted cuff tears, fibrous tissue bound the tendon-to-bone junction with healing. After the healing of the retracted cuff tears, continuity of nontendinous tissue was observed adjacent to the medially retracted tendon, which comprised more disorganized immature fibrous tissue than that in the nonretracted cuff tears. CLINICAL RELEVANCE: Unlike the healing of nonretracted rotator cuff tear, repairing of the "retracted" tendon end of cuff tear still resulted in retraction of the tendon back to its original position but being held down with fibrous tissue to the footprint.

Nontendinous healing after repairing of retracted rotator cuff tear: an imaging study.

BACKGROUND: Follow-up magnetic resonance imaging (MRI) after rotator cuff repair can sometimes demonstrate healing with nontendinous tissue that extends from the footprint to the retracted tendon end, which is inferred as fibrous tissue formation. The aim was to investigate this particular finding and its significance. METHODS: There were 494 eligible cases of healed supero-posterior medium-sized to massive rotator cuff repairs, after the exclusion of retears. A retrospective review was performed for the 3 groups that were divided according to their MRI appearances of healing: type I described the direct healing of the tendon to the footprint, whereas type II demonstrated the distinctive continuity of nontendinous tissue from the footprint to the retracted tendinous portion, and type III also showed a similar appearance but with obvious thinning of the tissue, without any evidence of defect confirmed on the routine outpatient ultrasonograph. RESULTS: Only 108 of 494 patients (21.9%) demonstrated type I healing, whereas the signs of nontendinous healing were evident for the rest, with the 116 patients (23.5%) being classified as type III with attenuation. Comparing the preoperative tendon retraction, 34.8% and 37.2% of the Patte stages 2 and 3, respectively, resulted in type III healing, which were significantly higher compared with that of stage 1 (15.3%, P < .001). Type III healing had the highest average preoperative Goutallier grades. The average postoperative visual analog scale and the American Shoulder and Elbow Surgeons (ASES) scores have improved significantly for all 3 groups (P < .05), with the ASES score being 86.1±15.9 for type I, 93.7±36.1 for type II, and 87.8±15.1 for type III without significant differences between the groups (P = .3). CONCLUSIONS: Only a fifth of the rotator cuff repairs led to a direct healing to the footprint, and the rest healed with MRI appearance of nontendinous tissue formation bridging the retracted tendinous portion and the footprint. These MRI appearances did not represent the true tendinous tissue formation between the torn end of the tendon and the bone after healing. Such appearances did not seem to affect the clinical outcomes.

Biceps Rerouting for Semirigid Large-to-Massive Rotator Cuff Tears.

PURPOSE: To compare clinical and radiographic results of arthroscopic rotator cuff repair (ARCR) with biceps rerouting (BR) and those of conventional repair for semirigid, large-to-massive rotator cuff tear. METHODS: We prospectively collected data of 111 patients who underwent either ARCR + BR (n = 59, group 1) or only ARCR (n = 52, group 2) for semirigid, large-to-massive rotator cuff tear between January 2016 and December 2018. We comparatively analyzed both groups with respect to preoperative factors including concomitant lesions of the long head of the biceps tendon (LHBT). Univariate logistic regression analysis was performed to identify predictive variables for occurrence of retear after ARCR + BR. RESULTS: Mean age of groups 1 and 2 were 62.8 and 63.7 years, respectively (P = .484). Mean follow-up period in groups 1 and 2 were 15.1 and 25.1 months, respectively (P = .102). Mean range of motion and functional scores improved significantly (P < .05) and comparably (P > .05) in both groups. In total, 11 (18.6%) and 25 (48.1%) patients from groups 1 and 2, respectively, showed retear of the repaired rotator cuff at final follow-up (P < .01). Of 45 group 1 patients who showed less than 50% partial tearing of the LHBT preoperatively, 6 (13.3%) experienced retear. Comparatively, of 14 patients with partial tearing involving more than 50% of the LHBT, 5 (35.7%) suffered postoperative retear. If the patients had partial tear involving more than 50% of LHBT preoperatively, the odds ratio (OR) to have retear was 4.222 (P = .037). Wider (OR, 1.445, P = .047) and thinner (OR, 0.166, P = .019) LHBT were the prognostic factors to have retear. Three (5.1%) group 1 patients showed the Popeye deformity at final follow-up. CONCLUSIONS: ARCR + BR for semirigid, large-to-massive rotator cuff tears effectively improved clinical and structural outcomes as also shown in the conventional repairs. However, the retear rate was significantly lower in patients who underwent ARCR + BR than those treated conventionally. Partial tearing involving more than 50% of the LHBT and wide and/or thin tendon morphology were significant risk factors for postoperative occurrence of retear. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative trial.

Effects of comorbidities on the outcomes of manipulation under anesthesia for primary stiff shoulder.

BACKGROUND: Studies on the effects of manipulation under anesthesia (MUA) for primary stiff shoulder when different comorbidities are present are lacking. Our aim was to assess how comorbidities influence the recovery speed and clinical outcomes after MUA. METHODS: Between April 2013 and September 2018, 281 consecutive primary stiff shoulders in the frozen phase treated with MUA were included in this study. We investigated the comorbidities of patients and divided them into the control (n = 203), diabetes mellitus (DM) (n = 32), hyperlipidemia (n = 26), and thyroid disorder (n = 20) groups. The range of motion (ROM) and clinical scores for each group before MUA and 1 week, 6 weeks, and 3 months after MUA were comparatively analyzed. We identified the ROM recovery time after MUA and the responsiveness to MUA. Then, subjects were subdivided into early and late recovery groups based on their recovery time and into successful and nonsuccessful MUA groups based on their responsiveness to MUA. RESULTS: Significant improvements in ROM and clinical scores at 3 months after MUA were observed in all groups. Significant differences in ROM among the 4 groups were also observed during follow-up (P < .05). The DM group had significantly lower ROM values, even at 3 months after MUA, compared with the control group. The ROM recovery speed after MUA was slowest in the DM group, followed by the thyroid disorder, hyperlipidemia, and control groups. Most (90.6%) of the DM group experienced late recovery. The proportion of nonsuccessful MUA was higher in the DM and thyroid disorder groups than that in the control and hyperlipidemia groups (P = .004). During follow-up, there were no differences among groups regarding the visual analog scale, University of California at Los Angeles shoulder, and Constant scores. CONCLUSION: The ROM recovery speed and responsiveness to MUA for primary stiff shoulder were poorer for the DM and thyroid disorder groups than for the control group. In particular, compared with any other disease, outcomes were poorer when the comorbidity was DM. If patients have comorbidities, then they should be informed before MUA that the comorbidity could affect the outcomes of treatment.

Incidence and risk factors of acromial fracture following reverse total shoulder arthroplasty.

BACKGROUND: The occurrence and related predictors of acromial fracture following reverse total shoulder arthroplasty (RTSA) have not been fully elucidated. The aim of this study was to determine the incidence and risk factors of acromial fractures after RTSA. METHODS: We conducted a multicenter, retrospective case-control study of 787 cases (29 in acromial fracture group and 758 in control group) that underwent RTSA performed by 6 surgeons. The mean duration of follow-up after RTSA was 31.6 ± 21.8 months (range, 12-136 months). Demographic variables (age, sex, arm dominance, body mass index, working status, bone mineral density [BMD]), clinical variables (preoperative diagnosis, previous operation, implant design, preoperative clinical scores, screw size in glenoid fixation, postoperative rehabilitation), and radiographic variables (acromial thickness, critical shoulder angle, deltoid length, humeral offset to lateral acromion) were investigated. To determine risk correlation, univariate analysis and multivariate logistic regression analysis with calculated odds ratios (ORs) were performed. RESULTS: Postoperative acromial fractures occurred in 29 of the 787 shoulders with RTSA (3.7%). Acromial fractures were detected at a mean of 10.0 months (range, 1-66 months) postoperatively. Univariate analysis revealed that the occurrence of an acromial fracture was significantly associated with a previous operation (38% [11 of 29] vs. 21% [156 of 758], P = .025) and BMD (-2.33 vs. -1.74, P = .013). Multivariate logistic regression analysis found that the occurrence of a postoperative acromial fracture was significantly associated with a previous operation (P = .034; OR, 2.91; 95% confidence interval, 1.08-7.84) and deltoid length (P = .004; OR, 1.04; 95% confidence interval, 1.01-1.07). CONCLUSION: Acromial fracture following RTSA is not an uncommon complication, with an overall incidence of 3.7%. A previous operation, increased deltoid length, and low BMD were risk factors of acromial fracture following RTSA.

Hematologic Expression After Shoulder Surgery: Normalization Curve of Serum Inflammatory Markers.

PURPOSE: To determine the normalization curves of the serologic markers including white blood cell (WBC) count, WBC differential for segmented neutrophil (WBC seg.), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) after elective shoulder surgery and to investigate the hematologic differences among different shoulder surgeries. METHODS: Seventy-seven patients underwent arthroscopic rotator cuff repair (RCR, group A), 44 patients had open rotator cuff repair (group B), and 84 patients had shoulder arthroplasty (group C). Peak and normalization times of markers were determined at preoperatively, postoperative day (POD) 1 and 2 days, 1 and 2 weeks, 1, 2, 3, 6 months, and 1 year after surgery. The normal ranges of serologic markers were set to WBC 4000 to10,000/µL, WBC seg. 40% to 60%, ESR 0 to 20 mm/h, and CRP 0 to 0.8 mg/dL. RESULTS: Groups reached peak mean WBC count and WBC seg. on POD 1; mean WBC count started decreasing on POD 2 but was within normal value afterwards. Mean WBC seg. decreased to normal value at 1 month postoperatively in group A and B and at 2 months postoperatively in group C. Mean ESR peaked at 2 weeks postoperatively and normalized after 1 month in groups A and B and 3 months in group C. Mean CRP levels peaked on POD 2 in all groups and normalized within 2 weeks postoperatively in groups A and B and 1 month postoperatively in Group C. Normalized values of WBC count, WBC seg., and ESR varied widely. In contrast, CRP showed a consistent undetectable median, upper and lower quartile values less than 0.5 after normalization. Mean serum ESR and CRP values at peak time were significantly greater in group C than in the other groups (P = .001). CONCLUSIONS: The mean CRP levels were normalized at 2 weeks after rotator cuff repair and at 1 month after arthroplasties. Unlike the other serologic markers, CRP had consistent normalized values of median, upper and lower quartile afterwards. The peak levels of the inflammatory markers were greater and therefore normalized slower following more invasive surgery. LEVEL OF EVIDENCE: Level III, case control study.

Assessment of postoperative acromial and subacromial morphology after arthroscopic acromioplasty using magnetic resonance imaging.

OBJECTIVE: To identify the morphological characteristics of the acromion and subacromial bursal space after arthroscopic acromioplasty using magnetic resonance imaging (MRI). MATERIALS AND METHODS: One hundred patients who received arthroscopic rotator cuff repair and acromioplasty each received at least three MRI examinations (preoperative, first immediate postoperative, and second follow-up imaging between 8 months and 1 year postoperatively). Changes over time in the thickness and morphology of the postoperative acromion as well as the subacromial bursal space were assessed. Clinical and radiological parameters were also analyzed to identify any association with changes in acromial morphology. RESULTS: Despite minimal acromial thinning observed at the first immediate postoperative state, the acromions showed significant thinning at the second postoperative MRI, with a mean reduction of 32%. Along with acromial thinning, an exaggerated concave contour of the acromial undersurface was observed in some patients. In the subacromial space, a loculated fluid collection developed in 91% of the patients at the second postoperative follow-up. No statistically significant association was noted between postoperative acromial thickness change and clinical or radiological factors (P value > 0.05). CONCLUSION: A significant delayed reduction in acromial thickness within approximately 1 year of arthroscopic acromioplasty is thought to be a normal postoperative feature. The simultaneous collection of a loculated, cyst-like fluid in the subacromial bursal space may be an important associated factor of postoperative acromial thinning.

Clinical Outcomes after Reverse Total Shoulder Arthroplasty According to Primary Diagnosis.

BACKGROUND: To compare the clinical outcomes of reverse total shoulder arthroplasty (RTSA) according to the primary diagnosis. METHODS: In 98 shoulders (97 patients), RTSA was performed for cuff tear arthropathy (45), massive rotator cuff tear without glenohumeral arthritis (31), posttraumatic arthritis (9), primary osteoarthritis (6), rheumatoid arthritis (4), and arthritis due to infection sequelae (3). The average age of the patients at surgery was 68.9 years (range, 46-84 years). The mean follow-up duration was 48.4 months (range, 24-85 months). RESULTS: In the overall series, the mean subjective pain score (visual analog scale) during motion decreased from 5.2 preoperatively to 1.8 at 2 years of follow-up. There were significant improvements in active forward flexion (preoperatively 51.5° to 121.8° at 2 years of follow-up). The average Constant score improved from 35.4 points to 57.8 points and UCLA score improved from 13.4 points to 28.8 points. The Constant score and UCLA score were 60.8 and 31.0 points, respectively, in patients with rheumatoid arthritis. The Constant score and UCLA score were 58.4 and 29.1 points, respectively, in patients with cuff tear disease and 55.7 and 27.7 points, respectively, in patients with posttraumatic arthritis. Patients' subjective satisfaction was 86.8 points in the overall series; highest in the patients with arthritis by infection sequelae (96.7 points) and lowest in the patients with posttraumatic arthritis (82.2 points). In terms of complications, there were 17 cases (17.3%) of scapular notching and 2 patients with suprascapular nerve irritation symptom, but no patients with permanent neuropathy. CONCLUSIONS: The range of forward flexion and abduction motion, pain relief, and functionality were improved after RTSA in not only patients with cuff tear disease but also those with other arthritic diseases. There was no difference in the clinical outcomes of RTSA between patients with cuff tear disease and those with other arthritic diseases.