Location and Size of the Reverse Hill-Sachs Lesion in Patients with Traumatic Posterior Shoulder Instability.

BACKGROUND: In patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion. METHODS: Forty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: 1) a primary or recurrent traumatic posterior shoulder dislocation, and 2) the initial event was caused by trauma. Patients were excluded if they had: 1) no history of trauma, 2) prior shoulder surgery, 3) no CT examination, or 4) seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head. RESULTS: The reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± SD) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing towards 2:09 on a clock face. Length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm, 11.1 ± 3.6 mm, respectively. CONCLUSION: The reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability.

Rotator Cuff Tears are Significantly More Frequent in Recurrent Shoulder Instability Patients With Initial Dislocation at Age 40 or Older.

PURPOSE: To investigate and compare the pathologies and clinical outcomes of patients with traumatic anterior shoulder instability who underwent arthroscopic stabilization at 40 years or older between shoulders with initial dislocation before age 40 years and at 40 years or after. METHODS: Shoulders that underwent arthroscopic stabilization for recurrent traumatic anterior shoulder instability at 40 years or older with a minimum of 2-year follow-up were included. The subjects were divided into 2 groups according to age at initial dislocation after propensity score matching to reduce potential bias: younger than 40 years (group 1) and 40 years or older (group 2). Radiographic findings, pathologies, clinical outcomes, and complications were compared between the groups. RESULTS: Group 1 included 56 shoulders in 56 patients (26 men and 30 women) with a mean age of 51 years (range, 40-77 years). Group 2 included 28 shoulders in 28 patients (13 men and 15 women) with a mean age of 51 years (range, 40-77 years). Glenoid bone loss was greater in group 1 than in group 2 (P = .004). Rotator cuff tears were more frequently observed in group 2 than in group 1 (P < .001). Both groups showed significant improvement in the West Ontario Shoulder Instability Index score (P < .001 for each) and flexion (P < .001 for each). The recurrence rate was 4% in group 1 and 7% in group 2. CONCLUSIONS: Rotator cuff tears are significantly more frequent in recurrent shoulder instability patients with initial dislocation at age 40 or older. Arthroscopic stabilization yielded a low recurrence rate and favorable outcomes with a good return-to-sport rate in patients 40 years or older. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Return to sports and physical work after anatomical and reverse shoulder arthroplasty.

BACKGROUND: No consensus has been reached on the return to sports or physical work after shoulder arthroplasty due to a shortage of literature. The purpose of this study was to investigate return to sports or physical work after anatomical total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA), as well as the clinical and radiographic outcomes. METHODS: The inclusion criteria were as follows: 1) aTSA or RSA between 2012 and 2017, and 2) patients who preoperatively participated in sports or physical work. The exclusion criteria were as follows: 1) revision arthroplasty, 2) fracture/dislocation, 3) fracture sequelae, 4) postinfection, and 5) <2-year follow-up. Sports and physical work were classified as low-, medium-, or high-load activities. Range of motion, Constant score, sport or work return, and radiographic findings were evaluated and compared between aTSA and RSA groups. RESULTS: The subjects who met the criteria were 90 shoulders in 86 patients. The aTSA group consisted of 30 shoulders (10 men and 20 women) with a mean age of 71 ± 8 years (range, 56-85). The RSA group consisted of 60 shoulders (39 men and 21 women) with a mean age of 72 ± 6 years (range, 56-83). Active range of motion significantly improved after surgery in all directions in the aTSA group but only in flexion and external rotation in the RSA group. Postoperative external and internal rotations, as well as postoperative Constant scores and satisfaction, were significantly better in the aTSA than in the RSA group. In the aTSA group, the return rate was 93%, and the complete return rate was 70%. In the RSA group, the return rate was 83%, and the complete return rate was 30%. The complete return rate was significantly higher in the aTSA than in the RSA group. Only one aTSA shoulder showed loosening of the glenoid implant, and 8 RSA shoulders demonstrated low-grade scapular notching. CONCLUSION: The return to sports or physical work rates after aTSA and RSA were high; however, the complete return rates were significantly higher in the aTSA group than in the RSA group. No radiographic failures were identified except for one asymptomatic glenoid loosening with a midterm follow-up.

Postoperative graft integrity affects clinical outcomes after superior capsule reconstruction using fascia lata autograft in posterior-superior rotator cuff tears: a multicenter study.

BACKGROUND: Previous studies have postulated that graft thickness and graft healing may be important factors for optimizing clinical outcomes of superior capsule reconstruction (SCR) for patients with irreparable rotator cuff tears (RCTs). However, the relationship between postoperative graft integrity and clinical outcomes after SCR remains unclear. We aimed to assess the relationship between postoperative graft integrity, including graft thickness and size of graft tear, and clinical outcomes after SCR in patients with irreparable RCTs. METHODS: This retrospective multicenter study included 188 patients (86 women, 102 men; mean age, 69.2 years; range, 49-87 years) with irreparable RCTs who underwent arthroscopic SCR using fascia lata autografts. Using magnetic resonance imaging, the graft integrity was evaluated postoperatively at or after 1 year and was classified, according to Hasegawa's classification, into 4 categories: type I-II, intact graft of sufficient thickness; type III, thinned graft without discontinuity; type IV, presence of a minor discontinuity; and type V, presence of a major discontinuity. We compared (1) baseline characteristics, (2) visual analog scale (VAS) for pain, (3) American Shoulder and Elbow Surgeons (ASES) score, (4) active shoulder range of motion, and (5) acromiohumeral distance (AHD) among 4 groups based on postoperative graft integrity. RESULTS: Magnetic resonance imaging scans revealed 152 shoulders (80.9%) with type I-II graft, 13 (6.9%) with type III graft, 13 (6.9%) with type IV graft, and 10 (5.3%) with type V graft. VAS and ASES scores significantly improved after SCR in all graft types (P < .0001 to P = .02). However, shoulders with type V grafts had significantly inferior postoperative VAS and ASES scores compared to those with type I-II grafts (P = .001 and P < .0001, respectively). Shoulders without graft tears (types I-II and III) showed significant improvements in shoulder elevation and internal rotation after SCR (P < .0001 to P = .02). In contrast, shoulders with large graft tears (type V) showed no significant improvement in shoulder range of motion. Postoperative acromiohumeral distance significantly increased only in shoulders with type I-II grafts (P < .0001). CONCLUSION: Postoperative graft thickness and size of graft tear affected clinical and radiographic outcomes after SCR using a fascia lata autograft. Patients with large graft tears had significantly inferior postoperative clinical scores compared to those with intact grafts of sufficient thickness, although arthroscopic SCR provided pain relief even in patients with graft tears. Shoulders with intact grafts of sufficient thickness restored glenohumeral stability and showed better clinical outcomes than those with graft thinning or tears.

Arthroscopic Repair of Isolated Subscapularis Tears Show Clinical and Structural Outcome Better for Small Tears Than Larger Tears.

Purpose: To retrospectively investigate the mid-term outcomes after arthroscopic repair of isolated subscapularis tears with a relatively large number of patients and to compare them by tear size. Methods: Medical records were reviewed for patients who underwent arthroscopic rotator cuff repair between 2010 and 2017 at our institute. The inclusion criterion was isolated subscapularis tears that underwent arthroscopic rotator cuff repair. The exclusion criteria were (1) previous rotator cuff surgery, (2) lack of imaging studies or clinical evaluation data, (3) neuromuscular diseases, and (4) <2-year follow-up. Range of motion, American Shoulder and Elbow Society score, and bear-hug or belly-press test were assessed pre- and postoperatively. Repair integrity was evaluated with magnetic resonance imaging at postoperative1 year. The clinical and imaging study outcomes were compared between smaller (Lafosse types 1-3) and larger (types 4 and 5) tears. Results: The subjects included 38 males and 8 females with a mean age of 59 years (range, 25-77 years). The mean follow-up was 36 months (range, 24-96 months). There were 13 type 1, 10 type 2, 12 type 3, 6 type 4, and 5 type 5 shoulders. Postoperative American Shoulder and Elbow Society scores were significantly better in smaller tears than larger tears: 93 ± 8 and 75 ± 14, respectively (P = .003). Smaller tears showed better postoperative internal rotation than larger tears (P = .004). Significant decrease of positive bear-hug or belly-press test was observed in smaller tears (preoperative, 25; postoperative, 11; P < .001), but there was no significant improvement in larger tears (preoperative, 11; postoperative, 9). The retear rate was significantly greater in larger tears (64%) than smaller tears (6%, P < .001). Conclusions: The clinical and structural outcomes after arthroscopic repair of isolated subscapularis tears were better in smaller tears than larger tears with a mid-term follow-up. Larger tears showed high retear rates with poorer improvement in active range of internal rotation and subscapularis strength. Level of Evidence: Level III, retrospective, comparative study.

Biceps tenotomy versus soft-tissue tenodesis in females aged 60 years and older with rotator cuff tears.

BACKGROUND: Recently, to treat the long head of the biceps tendon lesions in addition to rotator cuff repair has been recommended. However, the differences in clinical outcomes between biceps tenotomy and tenodesis for middle-aged and elderly females remains unclear. The purpose of this study was to compare the outcomes of biceps tenotomy and soft-tissue tenodesis that were performed concurrently with arthroscopic rotator cuff repair in ≥60-year-old females. METHODS: Female shoulders that underwent arthroscopic rotator cuff repair in our institute in 2016 were retrospectively reviewed. This study included 66 shoulders with concurrent biceps tenotomy or soft-tissue tenodesis: tenotomy group, 41 shoulders; soft-tissue tenodesis group, 25 shoulders. Clinical scores, biceps pain (visual analogue scale, VAS), Popeye deformity, and biceps strength (%contralateral side) were compared between the two groups. RESULTS: The mean age was significantly higher in the tenotomy group than the soft-tissue tenodesis group (72 ± 4 and 68 ± 6 years, respectively; P = 0.002). There were no significant differences in post-operative JOA and UCLA scores between the groups. VAS for biceps pain was significantly higher at postoperative 6 months in the tenotomy group than the soft-tissue tenodesis group (2.9 ± 2.5 and 1.7 ± 1.6, respectively, P = 0.03), though there were no significant differences at postoperative 3, 12, and ≥24 months. Subjective evaluation of Popeye deformity was not significantly different between the groups. Postoperative biceps strength was significantly lower in the tenotomy group than the soft-tissue tenodesis group (89.9% and 102.8%, respectively, P = 0.02). CONCLUSIONS: Both biceps tenotomy and soft-tissue tenodesis concurrent with rotator cuff repair in ≥60-year-old female patients resulted in good outcomes. Shoulders with soft-tissue tenodesis demonstrated earlier improvement in postoperative biceps pain and better postoperative biceps strength than those with tenotomy. There were no differences in objective and subjective Popeye deformity between tenotomy and soft-tissue tenodesis. The LHB procedures, tenotomy or tenodesis, can be selected depending on surgeons' preference.

Assessment of the Preserved Biceps Tendon After Arthroscopic Rotator Cuff Repair in Patients ≤ 55 Years.

PURPOSE: We assessed hypertrophy of preserved long head of the biceps tendon (LHBT) and vascularity in the bicipital groove after arthroscopic rotator cuff repair in ≤55-year-old patients and compared postoperative pain between shoulders with or without vascularity in the bicipital groove. METHODS: Patients who underwent arthroscopic rotator cuff repair between 2015 and 2017 were reviewed. Inclusion criteria were arthroscopic rotator cuff repair and ≤55 years old. Exclusion criteria were a history of contralateral rotator cuff repair, revision surgery, partial repair or superior capsular reconstruction, shoulder dislocation or fracture, torn LHBT at surgery, LHBT tenodesis, retears, <1-year follow-up, and incomplete follow-up data. Cross-sectional area (CSA) of the LHBT and vascularity in the bicipital groove were examined preoperatively and 1 year after surgery using ultrasonography. Shoulder pain at postoperative 1 year was assessed using the pain subscore of the University of California at Los Angeles scale. The data were compared between shoulders with negative and positive vascularity. RESULTS: Fifty-seven shoulders were included in this study. There was no side-to-side difference in preoperative CSA. No difference was found between preoperative and postoperative CSA in the affected shoulders. Postoperative vascularity was identified in 28 (49%) shoulders. Mean pain score was significantly higher in the negative vascularity group than the positive vascularity group (9 and 8, respectively; P = .002). CONCLUSIONS: The preserved LHBT did not show hypertrophy 1 year after arthroscopic repair of medium-sized or smaller posterosuperior rotator cuff tear in ≤55-year-old patients. However, 49% of the shoulders postoperatively demonstrated lower-grade vascularity in the bicipital groove. Healthy LHBT can be preserved in ≤55-year-old patients with posterosuperior medium-sized or smaller rotator cuff tears. LEVEL OF EVIDENCE: III, retrospective comparative prognostic trial.

Relationship between the morphology of the greater tuberosity and radiological and clinical outcomes after arthroscopic rotator cuff repair.

BACKGROUND: Degenerative greater tuberosity (GT) changes are often associated with rotator cuff tears. However, little is known about the impact of GT morphology on surgical outcomes. The aim of this study was to examine the relationship between clinical and radiological outcomes, after rotator cuff repair, and GT morphology. METHODS: We retrospectively investigated shoulders that underwent arthroscopic repair of nontraumatic full-thickness supra-/infraspinatus tears. The exclusion criteria were a lack of either radiographs or magnetic resonance images, revision surgery, partial repair, complications such as infection or dislocation, and follow-up < 2 years. GT morphology on radiographs was classified into 5 groups: normal, sclerosis, bone spur, roughness, and femoralization. The acromiohumeral interval (AHI) was measured on anteroposterior radiographs. Fatty degeneration of the cuff muscles was evaluated using the global fatty degeneration index (GFDI). Postoperative cuff integrity was classified using Sugaya's classification at 2 years after surgery. Clinical outcomes were assessed preoperatively and at postoperative 2 years with the Japanese Orthopaedic Association score and the University of California, Los Angeles shoulder rating scale. RESULTS: The study included 220 shoulders in 212 patients (104 men and 108 women), with a mean age of 66 years (range 43-85). The mean follow-up period was 28 months (range, 24-60 months). Seven shoulders (3.2%) were classified as normal, 65 (29.5%) as sclerosis, 55 (25.0%) as bone spur, 78 (34.5%) as roughness, and 15 (6.8%) as femoralization. The preoperative AHI, in the roughness and femoralization groups, was significantly smaller than that in the sclerosis (P < .01) and bone spur groups (P < .001). The roughness and femoralization groups had a greater number of large tears (P = .006). In the roughness and femoralization groups, mean GFDI was significantly higher than that in the sclerosis group (P < .001 for both). Repaired cuff integrity was not different between all groups, respectively. Both Japanese Orthopaedic Association and University of California, Los Angeles scores improved postoperatively from 73.3 to 95.6 points and 18.2 to 34.0 points (P < .001 for both), respectively, and there were no significant differences between all groups, respectively. CONCLUSION: Roughness or femoralization of the GT was related to larger tears, with smaller AHI and higher GFDI. Repaired cuff integrity and clinical outcomes in shoulders with roughness or femoralization of the GT were not inferior to shoulders with the other types of GT morphologies in this study. Arthroscopic repair can be indicated for shoulders with advanced changes of the GT, if fatty degeneration of the cuff muscles is not severe.

In vivo measurement of distance between scapular neck and polyethylene insert during active external rotation in shoulders with Grammont type reverse prosthesis.

BACKGROUND: Scapular notching is a frequently observed complication after reverse shoulder arthroplasty. Impingement of the humeral plastic insert against the scapular neck is believed to be the cause of notching. There have been no in vivo studies that analyzed the positional relationship between the scapular neck and humeral insert. The purpose of this study was to measure the distance between the scapular neck and insert in shoulders with Grammont-type prostheses during active external rotation at the side. METHODS: Eighteen shoulders with Grammont-type prostheses were enrolled in this study. There were 13 males and 5 females, and the mean age at surgery was 74 years (range, 63-91). Fluoroscopic images were recorded during active external rotation at the side from maximum internal to external rotation at an average of 14 months (range, 7-24) after surgery. Implant kinematics were determined with three-dimensional models of the implants and fluoroscopic images using model-image registration techniques. Based on the implant kinematics, the closest distance between the scapular neck and insert was computed at each 5° increment of glenohumeral internal/external rotation. RESULTS: Mean glenohumeral abduction during rotation was 17°-22°. The mean distance between the neck and insert was approximately 1 mm throughout the activity. The separation distance tended to narrow with arm external rotation, but the change was not significant. INTERPRETATION: The small distance between the scapular neck and insert in early post-operative reverse shoulder arthroplasty patients may be associated with the high incidence of scapular notching in Grammont-type prostheses.

Arthroscopic Soft Tissue Stabilization With Selective Augmentations for Traumatic Anterior Shoulder Instability in Competitive Collision Athletes.

BACKGROUND: Many surgeons prefer bony stabilization including Bristow or Latarjet procedures for shoulder instability in collision athletes, even though several potential complications have been reported. There has been a limited number of studies on the midterm outcomes of arthroscopic soft tissue stabilization for anterior shoulder instability in competitive collision athletes. PURPOSE: To assess the outcomes of arthroscopic soft tissue stabilization in combination with selective augmentation procedures for collision athletes with traumatic anterior shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively assessed rugby or American football players (<40 years old) who underwent arthroscopic Bankart or bony Bankart repair with selective augmentations (rotator interval closure and/or Hill-Sachs remplissage) for traumatic anterior shoulder instability between January 2012 and March 2017. Shoulders that required other bony procedures were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score and Subjective Shoulder Value sports score) were investigated. RESULTS: This study included 113 shoulders in 100 patients with a mean age of 20 years (range, 15-36 years) at surgery. Rotator interval closure was performed on 36 shoulders in addition to Bankart repair, and rotator interval closure and Hill-Sachs remplissage were performed on 77 shoulders. The mean follow-up period was 44 months (range, 24-72 months). Of the 113 shoulders, 4 (3.5%) experienced postoperative dislocation, but there were no complications. A total of 93 athletes (93%) attained complete or near complete preinjury sports activity levels. The mean Rowe score significantly improved from 36 (range, 10-75) at presurgery to 96 (range, 35-100; P = .003) at postsurgery. The mean Subjective Shoulder Value sports score significantly improved after surgery, from a mean preoperative score of 22 (range, 0-50) to a postoperative score of 92 (range, 64-100; P = .002). CONCLUSION: Our treatment strategy, where arthroscopic soft tissue stabilization was combined with selected augmentations, provided good clinical outcomes for competitive collision athletes in terms of low rates of recurrence and complication, a high rate of return to sports, and good shoulder function.

Arthroscopic Iliac Bone Grafting for Traumatic Anterior Shoulder Instability With Significant Glenoid Bone Loss Yields Low Recurrence and Good Outcome at a Minimum of Five-Year Follow-Up.

PURPOSE: The purpose of this study was to investigate the clinical and radiographic outcomes of arthroscopic iliac bone grafting with capsulolabral reconstruction for severe glenoid bone loss with a minimum of 5 years' follow-up. METHODS: The inclusion criterion was shoulders that underwent arthroscopic iliac bone grafting for >20%-25% glenoid defect between January 2007 and April 2014, and the exclusion criterion was <5 years' follow-up. Iliac crest bone grafts of approximately 2.0 cm length and 0.8 cm height were arthroscopically fixed to the anterior glenoid using 2 cannulated screws followed by capsulolabral repair. Rowe score, Western Ontario Shoulder Instability Index (WOSI), and passive range of motion were evaluated. Radiographic findings including the Kellgren and Lawrence osteoarthritis grade and graft integration on 3-dimensional computed tomography at the final follow-up were also evaluated. RESULTS: Forty-eight shoulders met the inclusion criteria, and 24 shoulders with ≥5 years' follow-up were included (1 died; 23 were lost follow-up): 22 males, 2 females; a mean age at surgery, 30 years (range, 18-52 years); a mean follow-up of 8 years (range, 5-11 years). The mean preoperative glenoid bone defect was 22% (range, 20%-28%). All shoulders had a Hill-Sachs lesion including 4 on-track lesions. One shoulder experienced traumatic redislocation at 5 years after surgery. The scores significantly improved: Rowe score, 19 ± 8 to 94 ± 8 (P < .001); WOSI, 1547 ± 241 to 439 ± 318 (P < .001). Postoperative flexion showed significant improvement from 158 ± 18 to 169 ± 11 (P = .008), whereas internal rotation deteriorated from T8 ± 3 to T10 ± 3 (P = .005). Graft integration showed remodeling in 54% and excessive absorption in 13%. Osteoarthritis grades progressed significantly (P < .001), but only grade 1 osteoarthritic changes were seen, except for 4 shoulders with grade 2 osteoarthritis. CONCLUSIONS: Arthroscopic iliac bone grafting for traumatic anterior shoulder instability with severe glenoid bone loss yielded satisfactory outcomes with mid-term follow-up. Arthritic changes progressed in half of the shoulders; however, most shoulders only demonstrated grade 1 osteoarthritis. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Comparison Between Osteochondral Autograft Transplantation and Arthroscopic Fragment Resection for Large Capitellar Osteochondritis Dissecans in Adolescent Athletes: A Minimum 5 Years' Follow-up.

BACKGROUND: The choice of surgical option for unstable large capitellar osteochondritis dissecans (OCD) lesions in skeletally immature athletes remains controversial. PURPOSE/HYPOTHESIS: The purpose was to investigate functional and radiographic outcomes after arthroscopic fragment resection and osteochondral autograft transplantation (OAT) for unstable large capitellar OCD lesions in skeletally immature athletes with a minimum 5 years' follow-up. We hypothesized that the outcomes after OAT for large capitellar OCD lesions would be superior to those after arthroscopic fragment resection. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 19 elbows in 19 patients (17 male and 2 females) who underwent arthroscopic resection were assigned to group 1 (mean age, 14 years [range, 13-15 years]), whereas 29 elbows in 29 patients (29 male) who underwent OAT were assigned to group 2 (mean age, 14 years [range, 13-15 years]), with the mean follow-up of 8 (range, 5-11 years) and 7 (range, 5-13 years) years, respectively. All OCD lesions were larger than one-half of the radial head diameter. Functional scores, patient satisfaction, and range of motion were compared between the groups. Radiographic changes, including superior migration, radial head enlargement, and osteoarthritis (OA) grade, were examined. RESULTS: All patients returned to sports activity. Functional scores, patient satisfaction, and flexion at the final follow-up were significantly improved in both groups compared with preoperative values, and differences were not significant between groups at the final follow-up. Extension showed a significant improvement in both groups (group 1: -17° to 0°; group 2: -18° to -6°; P < .001). Extension in group 1 was significantly better than that in group 2 at the final follow-up (P = .045). No elbows developed postoperative severe OA in group 1, whereas 3 elbows in group 2 had grade 3 OA; these 3 elbows had preoperative superior migration and radial head enlargement. CONCLUSION: No differences were observed in clinical and radiographic outcomes between patients undergoing arthroscopic fragment resection and OAT, except for elbow extension, at a minimum 5 years' follow-up. We believe that for adolescents with large capitellar OCD lesion, OAT is a good option for skeletally immature elbows and that arthroscopic fragment resection is a reliable and less invasive surgical option for relatively mature elbows.

Clinical outcomes of anatomic total shoulder arthroplasty for primary shoulder osteoarthritis did not differ between elderly and younger Japanese patients.

Background: Few studies on the outcomes of anatomic total shoulder arthroplasty (aTSA) in Asian populations have been reported. In addition, approximately one-third of primary aTSA were performed for patients 80 years or older in Japan, but the indication of aTSA for the primary shoulder osteoarthritis in the elderly population remained unclear. The purposes of this study were (1) to investigate clinical outcomes of aTSA in Japanese patients with primary glenohumeral osteoarthritis and (2) to compare clinical outcomes between patients 80 years or older and 70 years or younger. We hypothesized that aTSA would yield favorable outcomes in Japanese patients and that the outcomes of aTSA in patients 80 years or older would be comparable to those 70 years or younger. Methods: Patient records were retrospectively reviewed to collect patients who underwent aTSA for glenohumeral osteoarthritis between August 2011 and September 2017. The inclusion criterion of this study was aTSA performed for glenohumeral osteoarthritis. Exclusion criteria were as follows: (1) secondary osteoarthritis, (2) revision surgery, and (3) < 24-month follow-up. Range of motion (ROM) and Constant score were evaluated, and complications were investigated. Rotator cuff integrity was assessed by ultrasonography. We compared the outcomes between patients 80 years or older and 70 years or younger. Results: Seventy-seven shoulders (72 patients) met the study criteria. There were 14 men and 58 women with a mean age of 75 years (range, 57-93 years) at the time of surgery. The mean follow-up was 40 months (range, 24-84 months). The Constant score significantly improved from preoperative 54 (range, 35-78) to postoperative 89 (range 69-100, P = .03). Range of motion also showed significant improvement after surgery: flexion, 90° (range, 60°-130°) to 140° (range, 90°-170°); external rotation at the side, from 7° (range, -10 to 60°) to 40° (range, 5°-70°); internal rotation, from buttock (range, buttock-L3) to L2 level (range, buttock-T8) (P <.001 for all). Postoperative subscapularis tendon tears were detected in 3 shoulders (5%). Complications other than rotator cuff tears were observed in 5 shoulders (6%). Postoperative Constant score and ROM significantly improved in both elderly and younger patients without significant differences. Conclusion: The clinical outcomes after aTSA in the Japanese population demonstrated significant improvements in ROM and Constant score with a low complication rate in the mid-term follow-up. aTSA should be indicated even in elderly patients because they also demonstrated comparable outcomes to younger patients.

Superior Labral Injuries in Elite Gymnasts: Symptoms, Pathology, and Outcomes After Surgical Repair.

BACKGROUND: Superior labral anterior-posterior (SLAP) lesions are common among elite gymnasts and throwing athletes. Although SLAP lesions in throwers are well-described in the literature, no study has described the characteristics of SLAP lesions in gymnasts. We aimed to reveal the characteristics of SLAP lesions in gymnasts by comparing the location and extension of these lesions between gymnasts and throwers. HYPOTHESIS: The location and arc of SLAP lesions in gymnasts will be different from those in throwing athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included 27 shoulders in 20 males and 3 females with a mean ± SD age of 20 ± 2.5 years (range, 16-25 years). We performed debridement alone for shoulders with a stable lesion. Anterior and/or posterior labral repair was added for unstable SLAP lesions depending on the extension and stability of the lesions. We investigated symptoms, onset, return to sport (based on patient records), and subjective shoulder values. SLAP lesions were evaluated through use of the Snyder classification. The location and arc of SLAP lesions were determined from surgical records and videos and described by use of the right shoulder clockface method. During the same period, 65 baseball players (65 shoulders; all males; mean age, 23 ± 7.0 years; range, 16-44 years) underwent arthroscopic SLAP surgery. We compared the location and arc of SLAP lesions between gymnasts and baseball players. RESULTS: Symptoms during gymnastics included pain (100%), apprehension (48%), or catching (11%). We found that 20 shoulders had symptom onset during gymnastics, most commonly during rings events. Type II SLAP lesions were found in 17 shoulders, type III in 2 shoulders, and type IV in 8 shoulders. The mean center of SLAP lesions was at the 11:40 clockface position in 27 gymnasts and 10:40 clockface position in 65 baseball players, and the difference was statistically significant (P < .001). The mean arc of SLAP lesions was 125° in gymnasts and 140° in baseball players, and the difference was not significant. We performed debridement in 2 shoulders (7%) and labral repair in 25 shoulders (93%). After surgery, all patients returned to gymnastics. The mean subjective shoulder value was 35 (range, 10-90) preoperatively and 76 (range, 40-100) postoperatively. CONCLUSION: SLAP lesions in gymnasts were significantly located anteriorly compared with those in baseball players. All patients returned to gymnastics after arthroscopic surgery. Secure repair of SLAP lesions may be important for good surgical outcomes, because 50% of patients experienced preoperative shoulder apprehension.

Repair Integrity and Retear Pattern After Arthroscopic Medial Knot-Tying After Suture-Bridge Lateral Row Rotator Cuff Repair.

BACKGROUND: Type 2 failure is a big issue after suture-bridge rotator cuff repair, which may be because of stress concentration at the medial row stitches. We have been performing medial knot-tying after suture-bridge lateral row repair to avoid the stress concentration. This study aimed to evaluate clinical and radiological outcomes after arthroscopic rotator cuff repair using this technique. HYPOTHESIS: This technique would yield better radiological outcomes with a reduced type 2 failure rate compared with reported outcomes after conventional suture-bridge repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The inclusion criteria of this study were (1) full-thickness tears, (2) primary surgery, and (3) minimum 2-year follow-up with pre- and postoperative magnetic resonance imaging (MRI). We investigated active ranges of motion (forward elevation and external rotation), as well as the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA), scores preoperatively and at the final follow-up. RESULTS: This study included 384 shoulders in 373 patients (205 men and 168 women) with a mean age of 65 years (range, 24-89 years) at the time of surgery. The mean follow-up was 29 months (range, 24-60 months). There were 91 small, 137 medium, 121 large, and 35 massive tears. Postoperative MRI scans demonstrated successful repair in 324 shoulders (84.4%, group S) and retear in 60 shoulders (15.6%). Among 60 retears, 40 shoulders (67%) had type 1 failure (group F1) and 20 shoulders (33%) had type 2 failure (group F2). Forward elevation and external rotation significantly improved after surgery (P < .001 for both). Postoperative JOA and UCLA scores in group F2 were significantly lower than those in the other groups. CONCLUSION: The medial knot-tying after suture-bridge lateral row repair demonstrated excellent functional and radiological outcomes after surgery, with a retear rate of 15.6%. The type 2 failure showed significantly inferior functional outcomes; however, the rate of type 2 failure was less relative to previous studies using conventional suture-bridge techniques. Our technique could be a good alternative to conventional suture-bridging rotator cuff repair because it may reduce the rate of postoperative type 2 failure.

Return to Sport After Arthroscopic Rotator Cuff Repair in Middle-Aged and Elderly Swimmers.

BACKGROUND: No reports have been published on the clinical outcomes, including return to sport, after rotator cuff repair in middle-aged and elderly swimmers with rotator cuff tears. PURPOSE: To retrospectively investigate clinical outcomes and return to sport after arthroscopic rotator cuff repair in middle-aged and elderly swimmers. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients who underwent arthroscopic rotator cuff repair and met the following criteria were included: (1) age older than 45 years, (2) rotator cuff tears confirmed during surgery, (3) arthroscopic suture bridge rotator cuff repair, (4) primary surgery, and (5) swam more than once a week before surgery. The exclusion criteria were as follows: (1) irreparable large and massive tears, (2) shoulder instability, (3) arthritis or rheumatic disorders, or (4) less than 2-year follow-up. We investigated functional outcomes including range of motion; the University of California, Los Angeles (UCLA) score; the American Shoulder and Elbow Surgeons (ASES) score; return to swimming; and the return rates for each style of swimming. In addition, the functional outcomes and findings of magnetic resonance imaging were compared between the group with complete return and the group with incomplete or failed return. RESULTS: A total of 32 shoulders in 31 middle-aged and elderly swimmers (5 males, 26 females) were included. The mean age was 65 years (range, 47-78 years), and the mean follow-up was 47 months (range, 24-86 months). Return to swimming was achieved in 31 (97%) shoulders at a mean of 8 months (range, 3-24 months), and complete return was achieved in 18 (56%) shoulders at a mean of 12 months (range, 3-24 months). The return rate was 97% for freestyle, 83% for breaststroke, 74% for backstroke, and 44% for butterfly stroke. Postoperative UCLA and ASES scores were significantly higher in the group with complete return than in the group with incomplete or failed return (P = .001 and .01, respectively). Postoperative forward elevation was significantly better in the complete return group (P = .01). CONCLUSION: This study demonstrated that 97% of elderly swimmers who underwent arthroscopic rotator cuff repair could return to swimming. The complete return rate was 56%; however, the group with incomplete or failed return showed poorer active forward elevation. Freestyle had the highest complete return rate, whereas the butterfly stroke had the lowest return rate. It may be important to achieve good active forward elevation postoperatively to return to swimming.

Valgus stability is enhanced by flexor digitorum superficialis muscle contraction of the index and middle fingers.

BACKGROUND: Flexor digitorum superficialis (FDS) muscle provides dynamic stabilization and medial elbow support for ulnar collateral ligament (UCL). The FDS contraction significantly affects the medial joint distance (MJD) through grip contraction. However, it remains unclear whether FDS activity alone contributes to medial elbow stability, or together with the activation of the flexor digitorum profundus during grip contraction, and which finger's FDS is the main contributor to elbow stability. We investigated the resistive effects of isolated FDS contraction in individual fingers against valgus stress in the elbow joint using stress ultrasonography (US). METHODS: We investigated 17 healthy males (mean age, 27 ± 5 years). Valgus stress US was performed using the Telos device, with the elbow at 30° flexion. MJD was measured for each arm during 3 separate conditions: at rest (unloaded), under valgus load (50 N) (loaded), and under valgus load with FDS contracted in individual fingers (loaded-contracted). RESULTS: MJD was significantly longer when loaded (5.4 ± 0.4 mm) than unloaded (4.1 ± 0.2 mm, P = 0.007) or loaded-contracted (4.6 ± 0.3 mm, P = 0.003) for each finger. When loaded-contracted, MJD differed statistically between the index and ring fingers (P = 0.03) and between the middle and ring fingers (P = 0.04). However, the difference between the index and middle fingers was not statistically significant (P = 0.08). CONCLUSIONS: Individual FDS contraction, particularly of the index and middle fingers, contributes most to stabilization against valgus stress. Thus, injury care programs should incorporate FDS exercises of these fingers.

Incidence of Axillary Nerve Injury After Arthroscopic Shoulder Stabilization.

PURPOSE: To investigate the incidence of axillary nerve palsy after arthroscopic shoulder stabilization and to measure the distance between the nerve and capsule in shoulders with a capsular lesion. METHODS: This retrospective study included 2,027 shoulders (1,909 patients; 1,433 male and 476 female patients; mean age, 32 years [age range, 13-81 years]) subjected to arthroscopic soft-tissue stabilization for recurrent shoulder instability from 2005 to 2017. The exclusion criteria were bone grafting or transfer and preoperative axillary nerve symptoms. We retrospectively reviewed patient records and investigated the incidence and clinical features of axillary nerve palsy. We measured the closest distance between the axillary nerve and capsule on preoperative magnetic resonance images. RESULTS: Postoperative axillary nerve palsy occurred in 4 shoulders (0.2% of all arthroscopic stabilizations). Capsular repair was performed in 2 shoulders (1.2% of 160 capsular repairs); humeral avulsion of the glenohumeral ligament (HAGL) repair, 1 shoulder (2% of 47 HAGL repairs); and isolated Bankart repair, 1 shoulder (0.05% of 1,941 Bankart repairs). The closest distance between the nerve and capsule was 3.4 ± 3.2 mm in shoulders with capsular or HAGL lesions and less than 1 mm in the 3 shoulders with palsy. The common symptoms in axillary nerve palsy cases were shoulder discomfort, delayed recovery of range of motion, and deltoid weakness and atrophy. A definitive diagnosis was made with electromyography in all cases. Nerve injury by a suture was confirmed during revision surgery in 3 shoulders subjected to capsular or HAGL repair during the initial operation. The palsy was transient and fully recovered in 1 shoulder with isolated Bankart repair. CONCLUSIONS: The incidence of axillary nerve palsy after arthroscopic soft-tissue shoulder stabilization was low but higher in shoulders subjected to capsular or HAGL repair. We should always consider the possibility of axillary nerve palsy in shoulders that require capsular or HAGL repair. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Relationship between postoperative retear and preoperative fatty degeneration in large and massive rotator cuff tears: quantitative analysis using T2 mapping.

BACKGROUND: Fatty degeneration of the rotator cuff muscles is reported to be associated with retear after rotator cuff repair. The purpose of this study was to assess the relationship between retear and preoperative fatty degeneration, as quantified by T2 mapping. METHODS: This prospective cohort study included 83 large and 24 massive rotator cuff tears (average age, 67 years; range, 46-82 years). All patients preoperatively underwent T2 mapping magnetic resonance imaging, and T2 values of the supraspinatus and infraspinatus muscles were quantified. Cuff integrity was evaluated with magnetic resonance imaging 1 year postoperatively. Preoperative T2 values were compared between the retear and intact groups. The preoperative Goutallier stage, Constant score, and the shoulder score of the University of California at Los Angeles were also compared between the 2 groups. RESULTS: Retear was found in 32 shoulders (30%). Postoperative Constant and University of California at Los Angeles scores were significantly higher in intact shoulders than in retear shoulders (P < .001 for both). Mean preoperative T2 values of supraspinatus and infraspinatus were 77.4 ± 13.2 ms and 73.2 ± 15.3 ms in retear shoulders and 66.5 ± 11.1 ms and 58.6 ± 11.7 ms in intact shoulders, respectively; the differences were significant in both muscles (P < .001). Cutoff values for prediction of retear were 71.8 ms in supraspinatus and 63.1 ms in infraspinatus. There were no significant differences in the preoperative Goutallier stages of supraspinatus and infraspinatus between the 2 groups. CONCLUSIONS: Retear shoulders demonstrated significantly higher preoperative T2 values than intact shoulders. T2 mapping can be a useful tool for predicting postoperative retears.

Preoperative Pain Control in Arthroscopic Rotator Cuff Repair: Does It Matter?

BACKGROUND: The purpose of this study was to clarify the importance of preoperative pain control using corticosteroid injections in patients with persistent rest pain (RP) before arthroscopic rotator cuff repair (ARCR). METHODS: A total of 360 patients (374 shoulders) who underwent primary ARCR and were followed up for at least 2 years were enrolled. After one-to-one propensity score matching, 266 patients (145 men and 128 women, 273 shoulders) were included in the study. Their mean age was 65.2 ± 7.7 years (range, 42 to 88 years) at the time of surgery. The patients were divided into three groups: those who required several intra-articular or subacromial bursa corticosteroid injections preoperatively for refractory RP (group A+), those in whom RP was resolved preoperatively (group A-), and those who had no RP and did not require any injections (group B). The incidence of postoperative RP and preoperative and final follow-up American Shoulder and Elbow Surgeons (ASES) scores were compared among the three groups. RESULTS: The incidence of postoperative RP was significantly higher in group A+ (35/91 cases, 38.5%) than in group A- (10/91, 11.0%) and group B (7/91, 7.7%, p < 0.001 for both). The preoperative ASES score was significantly lower in group A+ (33.2 ± 14.2) than in group A- (53.9 ± 11.9) and group B (62.3 ± 11.2, p < 0.001 for both), and it was significantly lower in group A- than in group B (p = 0.000). The final follow-up ASES score was significantly lower in group A+ (92.1 ± 8.4) than in group A- (97.6 ± 5.4) and group B (99.0 ± 2.5, p < 0.001 for both). There was no significant difference in the final follow-up ASES score between group A- and group B (p = 0.242). CONCLUSIONS: Patients in whom preoperative RP could be resolved before surgery achieved postoperative outcomes comparable to those in patients who had no RP before surgery, whereas the outcomes in patients with refractory preoperative RP were inferior. The results suggest that preoperative pain control is important in patients undergoing ARCR.