Superior Capsular Reconstruction: A Salvage Option for Massive Irreparable Rotator Cuff Tears with Pseudoparalysis or Subscapularis Insufficiency.

PURPOSE: We sought to examine superior capsular reconstruction (SCR) outcomes after minimum 2-year follow-up and determine risk factors that were predictive of outcomes. METHODS: Forty consecutive patients (mean age 57.3 years, 87.5% male) who underwent SCR for massive irreparable rotator cuff tears (RCT) met the inclusion criteria. Minimum 2-year follow-up was obtained for 32 patients (80% follow-up). Patient demographics and preoperative clinical findings were collected. Postoperative data, including complications, patient satisfaction, strength and range-of-motion (ROM), and patient-reported outcomes were collected. RESULTS: The Hamada score was ≤2 in 88% with average acromiohumeral interval distance of 6.8 mm. Preoperatively, 6 patients had external rotation lag (19%) and 6 had pseudoparalysis (19%). Intraoperative assessment of the subscapularis demonstrated true insufficiency in 38%. There was significant improvement in forward elevation (FE) (31° increase; P = .007) and strength in all planes (all P < .05). Patient-reported outcomes significantly improved (American Shoulder and Elbow Surgeon [ASES] 34-point increase; visual analog scale [VAS] 2.9-point decrease; single alpha-numeric evaluation [SANE] 48-point increase; all P < .05). Twenty-six patients (81%) were completely or somewhat satisfied with surgery. At time of final follow-up, 3/32 patients (9%) failed SCR and converted to reverse total shoulder arthroplasty. There were 4 (13%) reported complications (2 patients had postoperative falls; 1 patient had persistent severe pain; 1 had persistent stiffness). One patient was deceased. Patients with pseudoparalysis (n = 6) had significant improvement in post-operative FE (28 vs 154°; P < .0001) and SANE score (P = .016) with 66% patient satisfaction. However, outcome scores overall remained lower than SCR without pseudoparalysis. Regarding subscapularis insufficiency (n = 12), significant improvement was seen in postoperative FE (108 vs 158°; P = .019) and patient-reported outcome scores (P < .005). In patients converted from SCR to reverse total shoulder arthroplasty (n = 3), there were no distinguishing characteristics present. CONCLUSION: Superior capsular reconstruction is an effective salvage operation for massive irreparable RCT. Patients with pseudoparalysis or subscapularis insufficiency demonstrate significant postoperative improvement in FE and patient-reported outcomes. LEVEL OF EVIDENCE: IV, retrospective cohort.

Pectoralis muscle injuries in Major and Minor League Baseball.

BACKGROUND AND HYPOTHESIS: Although shoulder and elbow injuries in professional baseball players have been thoroughly studied, little is known about the frequency and impact of pectoralis muscle injuries in this population. The purpose of this study was to use the official league injury surveillance system to describe pectoralis muscle injuries in professional baseball players in Major League Baseball (MLB) and Minor League Baseball (MiLB). Specifically, (1) player demographic characteristics, (2) return to play (RTP), (3) injury mechanism, (4) throwing- and batting-side dominance, and (5) injury rate per athlete exposure (AE) were characterized to guide future injury prevention strategies. METHODS: The MLB Health and Injury Tracking System database was used to compile all pectoralis muscle injuries in MLB and MiLB athletes in the 2011-2017 seasons. Injury-related data including diagnosis (tear or rupture vs. strain), player demographic characteristics, injury timing, need for surgical intervention, RTP, and mechanism of injury were recorded. Subanalyses of throwing- and batting-side dominance, as well as MLB vs. MiLB injury frequency, were performed. RESULTS: A total of 138 pectoralis muscle injuries (32 MLB and 106 MiLB injuries) were reported in the study period (5 tears or ruptures and 133 strains), with 5 of these being recurrent injuries. Operative intervention was performed in 4 athletes (2.9%). Of the 138 injuries, 116 (84.1%) resulted in missed days of play, with a mean time to RTP of 19.5 days. Starting pitchers sustained the greatest proportion of pectoralis injuries (48.1%), with pitching being the most common activity at the time of injury (45.9%). A majority of injuries (86.5%) were sustained during non-contact play. Overall, 87.5% of injuries occurred on the player's dominant throwing side and 81.3% occurred on the player's dominant batting side. There was no significant difference in the rate of pectoralis injuries in the MLB regular season (0.584 per 10,000 AEs) vs. the MiLB regular season (0.425 per 10,000 AEs) (P = .1018). CONCLUSION: Pectoralis muscle injuries are most frequently non-contact injuries, most commonly sustained by pitchers. An understanding of these injuries can guide athletic trainers and management in expectation management and decision making, in addition to directing future efforts at injury prevention.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts.

BACKGROUND: Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited. METHODS: We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates. RESULTS: A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men. CONCLUSIONS: Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study.

PURPOSE: To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS: As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS: After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS: Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE: I, prognostic study.

Evolving Expectations of the Orthopedic Team Physician: Managing the Sidelines and Landmines.

ABSTRACT: The role of orthopedic team physicians has evolved greatly over the past decade having been influenced by advances in sports science and performance, new surgical and biologic technologies, social media, medicolegal liability, marketing, and sexual misconduct cases by some team physicians. The great variety of events and sports that are covered from high school and collegiate to the Olympic and professional levels requires a myriad of skills outside of the traditional medical training curriculum. In the current climate of increasing media scrutiny from a 24-h news cycle it is imperative for orthopedic team physicians, whether operative or nonoperative, to continually adapt to the needs and expectations of athletes who also are patients. This is especially true in the wake of the COVID-19 pandemic. Orthopedic team physicians' responsibilities continue to evolve ensuring their relevance and necessity on the sidelines and in the training room as well as in the operative suite.

Factors Influencing Surgeon's Choice of Procedure for Anterior Shoulder Instability: A Multicenter Prospective Cohort Study.

PURPOSE: To investigate preoperative factors associated with selection of surgical treatment for anterior shoulder instability. METHODS: Patient demographics, initial physical examinations, and patient-oriented outcome questionnaires were collected prospectively from 26 shoulder surgeons at 10 sites. Symptom duration, number of dislocations, sport, history of prior stabilization procedure, Hill-Sachs/glenoid bone loss, pain level, and failure of conservative treatment were recorded. Statistical analysis was performed with Fisher's exact test and logistic regression analysis. RESULTS: A total of 564 patients who underwent surgical treatment for anterior shoulder instability from November 2012 to June 2017 were enrolled. Of these, 426 shoulders underwent arthroscopic stabilization alone, 38 underwent arthroscopic stabilization with remplissage, 28 underwent open Bankart repair, and 72 underwent a Latarjet procedure. Predictors for undergoing Latarjet (P < .003) were symptom duration (75% had symptoms for >1 year), number of dislocations (47% had >5 dislocations), revision surgery (69%), Hill-Sachs lesion size (45% had a lesion between 11% and 20% of the humeral head), and glenoid bone loss (75% of Latarjet patients had 11% to 30% loss). Predictors for undergoing open Bankart repair (P < .001) were number of dislocations (32% had >5 dislocations), revision surgeries (54%), and glenoid bone loss (11% of open Bankart patients had 11% to 20% loss). History of prior shoulder surgery was the only significant predictor of open versus arthroscopic Bankart procedure. Prediction models showed athletes involved in high-risk sports were 2.61 times more likely to have a Latarjet (P < .01). CONCLUSIONS: Indications for the Latarjet were: humeral and glenoid bone loss, duration of symptoms, number of dislocations, and revision stabilizations. Athletes involved in high-risk sports were more likely to undergo the Latarjet procedure, even if other predictive factors were not present. The open Bankart procedure was the least common procedure performed, with a history of prior shoulder surgery being the only predictor for use when treating recurrent instability. LEVEL OF EVIDENCE: Level II, prospective prognostic cohort investigation.

A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors.

HYPOTHESIS: We evaluated the correlation of preoperative factors with pain after arthroscopic rotator cuff repair (ARCR). We hypothesized that nonstructural factors, including metrics of psychological well-being and preoperative narcotic use, would correlate with higher pain levels postoperatively and that structural factors, such as tear size, would not be predictive. METHODS: Ninety-three patients were prospectively enrolled and evenly distributed by tear size. Patient sex, age, occupation, smoking status, tear mechanism, tear characteristics on magnetic resonance imaging, visual analog scale (VAS) pain scores, narcotic usage, range of motion (ROM) by goniometry, and functional and psychological assessments through the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Simple Shoulder Test, Western Ontario Rotator Cuff Index (WORC), and RAND 36-item Short Form Survey questionnaires were obtained preoperatively. VAS scores and ROM were collected postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The ASES, SST, WORC, and RAND 36-item Short Form Survey questionnaires were repeated 1 year postoperatively. RESULTS: The patients (54% men) were a mean age of 56.4 years. There were 68% traumatic tears, 11% smokers, and 13% used narcotics preoperatively. ROM, VAS, ASES, and WORC scores improved significantly from the preoperative to 1-year postoperative assessment. Correlating with increased pain scores at 1 year were preoperative narcotic use, higher preoperative VAS, and lower scores on the WORC index and emotion sections. CONCLUSION: Our data show that the factors most predictive of persistent pain after ARCR are psychosocial characteristics, including poor performance on validated measures of emotional well-being. Demographic and tear-specific structural factors did not correlate with postoperative pain scores.

2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomatic, full-thickness rotator cuff tears.

BACKGROUND: The purpose of this study is to help define the indications for rotator cuff repair by identifying predictors of failure of nonoperative treatment. METHODS: A prospective, multicenter, cohort study design was used. All patients with full-thickness rotator cuff tears on magnetic resonance imaging were offered participation. Baseline data from this cohort were used to examine risk factors for failing a standard rehabilitation protocol. Patients who underwent surgery were defined as failing nonoperative treatment. A Cox proportional hazards model was fit to determinethe baseline factors that predicted failure. The dependent variable was time to surgery. The independent variables were tear severity and baseline patient factors: age, activity level, body mass index, sex, Single Assessment Numeric Evaluation score, visual analog scale score for pain, education, handedness, comorbidities, duration of symptoms, strength, employment, smoking status, and patient expectations. RESULTS: Of the 433 subjects in this study, 87 underwent surgery with 93% follow-up at 1 year and 88% follow-up at 2 years. The median age was 62 years, and 49% were female patients. Multivariate modeling, adjusted for the covariates listed previously, identified patient expectations regarding physical therapy (P < .0001) as the strongest predictor of surgery. Higher activity level (P = .011) and not smoking (P = .023) were also significant predictors of surgery. CONCLUSION: A patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear. As such, patient symptoms and anatomic features of the chronic rotator cuff tear may not be the best features to use when deciding on surgical intervention.

The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears.

HYPOTHESIS: The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength. METHODS: We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12 months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms. RESULTS: A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures. CONCLUSIONS: There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease.

2024 Kappa Delta Ann Doner Vaughan Award Nonsurgical Treatment of Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears-a Prospective Multicenter Cohort Study With 10-Year Follow-Up.

The Multicenter Orthopaedic Outcomes Network Shoulder Group conducted a prospective cohort study of 452 patients with symptomatic atraumatic rotator cuff tears treated with a physical therapy program to determine the predictors of failure of nonsurgical treatment, to provide insight into indications for surgery. After 10 years, we found the following: (1) Physical therapy was effective for over 70% of patients. (2) PROMs showed statistical and clinical improvement after 12 weeks of therapy and did not decline over 10 years. (3) Cuff tear severity did not correlate with pain, duration of symptoms, or activity level. (4) Of those who had surgery, 56.7% had surgery in the first 6 months while 43.3% had surgery between 6 months and 10 years. (5) Early surgery was primarily driven by low patient expectations regarding the effectiveness of therapy. (6) Later surgery predictors included workers' compensation status, activity level, and patient expectations. (7) Only 1 patient had a reverse arthroplasty (0.2% of the cohort). These data suggest that physical therapy is an effective and durable treatment of atraumatic symptomatic rotator cuff tears and most patients successfully treated with physical therapy do not exhibit a decline in patient-reported outcomes over time. Reverse arthroplasty after nonsurgical treatment is exceptionally rare.

Obesity is associated with muscle atrophy in rotator cuff tear.

Objective: The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears. Methods: This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis. Results: A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear. Conclusions: Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients. Level of Evidence: III.

The Predictors of Surgery for Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears Change Over Time: Ten-Year Outcomes of the MOON Shoulder Prospective Cohort.

BACKGROUND: A prospective cohort study was conducted to assess the predictors of failure of nonoperative treatment, defined as the patient undergoing surgery for symptomatic, atraumatic full-thickness rotator cuff tears. We present the 10-year follow-up data of this population to determine if predictors for surgery change over time, and secondarily we report the outcomes of the cohort. METHODS: At the time of enrollment, demographic, symptom, rotator cuff anatomy, and patient-reported outcome data were collected in patients with symptomatic, atraumatic full-thickness rotator cuff tears. Patients underwent a standard physical therapy protocol for 6 to 12 weeks. Patient data were then collected at 1, 2, 5, 7, and 10 years. Failure of nonoperative treatment was defined as the patient electing to undergo surgery. RESULTS: Of the 452 patients in the original cohort, 20 patients (5%) withdrew from the study, 37 (9%) died before 10 years, and 40 (9%) were otherwise lost to follow-up. A total of 115 patients (27.0%) underwent a surgical procedure at some point during the 10-year follow-up period. Of these patients, 56.5% underwent surgery within 6 months of enrollment and 43.5%, between 6 months and 10 years. Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery. Workers' Compensation status and activity level were more important predictors of later surgery. Patient-reported outcome measures all improved following physical therapy. For patients who did not undergo a surgical procedure, patient-reported outcome measures did not decline over the 10-year follow-up period. CONCLUSIONS: Low patient expectations regarding the efficacy of physical therapy were found to be a predictor of early surgery, whereas Workers' Compensation status and activity level were predictors of later surgery. Physical therapy was successful in >70% of patients with symptomatic, atraumatic full-thickness rotator cuff tears at 10 years. Outcome measures improved with physical therapy and did not decline over the 10-year follow-up period. LEVEL OF EVIDENCE: Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.

3-D CT is the most reliable imaging modality when quantifying glenoid bone loss.

BACKGROUND: Posttraumatic anterior shoulder instability is associated with anterior glenoid bone loss, contributing to recurrence. Accurate preoperative quantification of bone loss is paramount to avoid failure of a soft tissue stabilization procedure as bone reconstruction is recommended for glenoid defects greater than 20% to 27%. QUESTIONS/PURPOSES: We determined whether radiography, MRI, or CT was most reliable to quantify glenoid bone loss in recurrent anterior shoulder instability. METHODS: Seven intact fresh-frozen human cadaveric shoulders were imaged with radiography, MRI, CT, and three-dimensional (3-D) CT. Three sequential anterior glenoid defects then were created, measured, and the shoulders reimaged after each defect. Defect sizes were less than 12%, 12% to 25%, and 25% to 40%. The gold standard measurement was determined by comparing measurements taken on the cadaver by two surgeons using digital calipers with the measurements determined by using electronic digital calipers on the 3-D CT. This measurement was used for comparison of all estimations by the evaluators. Twelve independent blinded evaluators reviewed the 112 image sets and estimated the percent of glenoid bone loss. Images were scrambled and rereviewed by the same observers 2 months later to determine intraobserver reliability. We determined reliability with kappa values. RESULTS: Kappa values between predicted bone loss versus true loss (determined by our gold standard measurements) across all 12 raters for each modality were: 3-D CT, 0.50; CT, 0.40; MRI, 0.27; and radiographs, 0.15. Interobserver agreement (kappa) values were: 3-D CT, 0.54; CT, 0.47; MRI, 0.31; and radiographs, 0.15. The intraobserver agreement (kappa) values were: 3-D CT, 0.59; CT, 0.64; MRI, 0.51; and radiographs, 0.45. CONCLUSIONS: Three-dimensional CT was the most reliable imaging modality for predicting glenoid bone loss. Regular CT was the second most reliable and reproducible modality.

Comparison of various imaging techniques to quantify glenoid bone loss in shoulder instability.

INTRODUCTION: The purpose of this study was to determine the most accurate imaging modality to quantify glenoid bone loss in recurrent anterior shoulder instability. This will allow the best preoperative prediction for patients needing a bone graft. MATERIALS AND METHODS: Seven fresh frozen shoulder cadavers were imaged with radiographs, magnetic resonance imaging (MRI), computed tomography (CT), and 3-dimensional CT (3-D CT). Native shoulders were imaged, and 3 sequential anterior-inferior glenoid defects were created, measured, and reimaged. Defect sizes were <12.5%, 12.5% to 27%, and >27%. Four blinded evaluators (2 musculoskeletal radiologists, 2 shoulder fellowship-trained surgeons) reviewed the 112 image sets and estimated the percentage of glenoid bone loss. Images were scrambled and re-reviewed by the same observers 2 months later to determine intraobserver reliability. RESULTS: Pearson correlation coefficients between predicted vs true bone loss across all 4 raters were 0.875 (3-D CT), 0.831 (CT), 0.693 (MRI), and 0.457 (x-ray imaging). Prediction errors (PE) were (mean ± SD in percentages) 3-D CT (-3.3 ± -6.6), CT (-3.7 ± -8.0), MRI (-2.75 ± -10.6), and x-ray images (-6.9 ± -13.1). Mean PE values were not significantly different among 3-D CT, CT, and MRI; however, the PE SDs were similar among the 4 evaluators for 3-D CT and lower than all other imaging techniques. Prediction based on x-ray images had the largest PE and SD. Covariance parameters revealed large variances for shoulders for MRI and x-ray imaging. The intraobserver intraclass correlation coefficients were 0.947 (3-D CT), 0.927 (CT), 0.837 (MRI), and 0.726 (x-ray image). CONCLUSIONS: The most accurate imaging modality in predicting glenoid bone loss among the 4 blinded independent evaluators was 3-D CT.

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study.

PURPOSE: To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design. MATERIALS AND METHODS: Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores. RESULTS: The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. CONCLUSION: Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years.

Return to Sport and Patient-Reported Outcomes After Subpectoral Biceps Tenodesis for SLAP Tear in Collegiate Gymnasts.

Background: The biceps superior labral complex is a known source of shoulder dysfunction in young, high-level athletes. Superior labral anterior-posterior (SLAP) repairs are often unsatisfactory for treating biceps-labral pathology in this demographic group, with high failure rates and poor return to sport (RTS). Minimal data have been published to demonstrate patient-reported outcomes (PROs) and RTS in gymnasts after treatment of SLAP pathologies. Hypothesis: Gymnasts undergoing biceps tenodesis for SLAP pathologies would have satisfactory PROs and satisfactory RTS. Study Design: Case series; Level of evidence, 4. Methods: Gymnasts aged ≤25 years who underwent open subpectoral biceps tenodesis for SLAP tears with or without biceps tendon pathology between August 20, 2014, and August 20, 2019, and who had minimum 2-year follow-up data were included in this study. Tenodesis was performed using a subpectoral technique with bicortical button fixation. The following PROs were included: RTS, postoperative activity level, 10-point visual analog scale for pain (VAS-Pain), American Shoulder and Elbow Surgeons (ASES), and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: Of 16 shoulders in 14 gymnasts undergoing biceps tenodesis for SLAP tear during the study period, a follow-up was obtained for 13 of 16 shoulders (81%) at 4.3 ± 1.5 years. The mean age of patients at the time of surgery was 21.8 ± 2.2 years, with 12 (92%) male patients. Biceps tenodesis was performed as the primary procedure for the diagnosis of SLAP tear in 12 patients (92%) and for failed prior SLAP repair in 1 patient (8%). PROs were excellent at the follow-up, with VAS-Pain scores of 1.8 ± 1.7, ASES scores of 89.1 ± 9.1, and DASH scores of 2.4 ± 3.2. After surgery, 8 (62%) patients returned to their prior level of collegiate gymnastics. Three (60%) of 5 patients did not return to collegiate gymnastics because of the end of eligibility, and 2 (40%) patients did not return to collegiate gymnastics because of knee injuries. Significantly higher DASH scores were noted in the group that did not RTS (P = .04). No patients experienced postoperative complications or reoperation. Conclusion: Biceps tenodesis was an effective primary operation for high-level gymnasts with SLAP tears, with a satisfactory rate of return to the same level of sport and excellent PROs.

Development and Validation of a Short-Form Version of the Western Ontario Shoulder Instability Scale (Short-WOSI).

BACKGROUND: Patient-reported outcome measures (PROMs) have transitioned from primarily being used as research instruments to becoming increasingly used in the clinical setting to assess recovery and inform shared decision-making. However, there is a need to develop validated short-form PROM instruments to decrease patient burden and ease incorporation into clinical practice. PURPOSE: To assess the validity and responsiveness of a shortened version of the Western Ontario Shoulder Instability Index (Short-WOSI) when compared with the full WOSI and other shoulder-related PROM instruments. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: This study was a secondary analysis of data collected as part of an institutional review board-approved, multicenter cohort of 1160 patients undergoing surgical stabilization for shoulder instability. The following PROMs were captured preoperatively and 2 years after surgery: WOSI, American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and 36-Item Health Survey (RAND-36). The cohort was split into 2 data sets: a training set to be used in the development of the Short-WOSI (n = 580) and a test set to be used to assess the validity and responsiveness of the Short-WOSI relative to the full WOSI, ASES, SANE, and RAND-36. RESULTS: The Short-WOSI demonstrated excellent internal consistency before surgery (Cronbach α = .83) and excellent internal consistency at the 2-year follow-up (Cronbach α = .93). The baseline, 2-year, and pre- to postoperative changes in Short-WOSI and WOSI were closely correlated (r > 0.90), with both demonstrating large effect sizes (Short-WOSI = 1.92, WOSI = 1.81). Neither the Short-WOSI nor the WOSI correlated well with the other PROM instruments before (r = 0.21-0.33) or after (r = 0.25-0.38) surgery. The Short-WOSI, WOSI, and SANE scores were more responsive than ASES and RAND-36 scores. CONCLUSION: The 7-item Short-WOSI demonstrated excellent internal consistency and a lack of floor or ceiling effects. The Short-WOSI demonstrated excellent cross-sectional and longitudinal construct validity and was similarly responsive over time as the full WOSI. Neither the Short-WOSI nor WOSI correlated with more general shoulder PROMs, underscoring the advantage of using instability-specific instruments for this population.

Factors Associated With Humeral Avulsion of Glenohumeral Ligament Lesions in Patients With Anterior Shoulder Instability: An Analysis of the MOON Shoulder Instability Cohort.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. Purpose: To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups. Results: A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001). Conclusion: Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions.

Operative management of capitellar fractures: a systematic review.

PURPOSE: This study was conducted to evaluate reports of clinical outcomes of isolated capitellar fractures. MATERIALS AND METHODS: We conducted a systematic review of medical databases reporting clinical outcomes of patients undergoing nonoperative and operative management of isolated capitellar fractures. RESULTS: We identified 28 studies for inclusion comprising 174 patients. All included studies were level IV evidence. Capitellar fractures were more common among women than men and were more likely to involve the nondominant arm. Type I fractures (84%) were more common than type II (14%) and III fractures (2%). Operative and nonoperative management both led to satisfactory clinical outcomes. No significant difference in outcomes was observed in those undergoing operative management compared with those undergoing closed reduction and immobilization. CONCLUSIONS: Nonoperative and operative management of isolated capitellar fractures leads to satisfactory clinical outcomes as determined by postoperative range of motion, improvement in pain, and a return to previous levels of function. No statistical difference in outcomes was observed between those undergoing operative management compared with those treated with closed reduction and immobilization.

The quality and accuracy of direct-to-consumer biologic marketing for shoulder pathology are poor.

Background: The growing role of biologic therapies as adjunct or standalone procedures in orthopedic practice has led to greater levels of direct-to-consumer biologic marketing. The present study aims to assess the quality, accuracy, and readability of online educational resources available to patients regarding biologic therapies for shoulder pathology. Methods: Eight search terms relevant to shoulder biologic therapies (shoulder + BMAC, Bone Marrow Aspirate Concentrate, PRP, Platelet Rich Plasma, Lipogems, Adipose Tissue, Biologic therapy, and Stem cell therapy) were searched across three separate search engines. The first 25 websites of each search were recorded. Duplicate websites and those not specific to shoulder pathology were excluded. Three evaluators independently assessed quality using an author-derived scoring rubric for a total of 25 possible points and accuracy for a total of 12 possible points. The Flesch-Kincaid readability test was used to quantify reading levels. Websites were further characterized by authorship and the presence of commercial bias. Results: Of the 600 results from the initial search, 59 met inclusion criteria. The mean quality of the websites was poor, with 7.97 ± 2.3 of 25 points (32%). The mean accuracy was low, with 8.47 ± 1.52 of 12 points (71%). The average reading level was 11.2 ± 1.93, with 32% of websites' reading at greater than 12th grade reading level. The search terms of "shoulder PRP" and "shoulder Platelet Rich Plasma" yielded the highest quality results (mean = 8.14 ± 2.63). "shoulder Lipogems" and "shoulder Adipose tissue" yielded the most accurate results (mean = 9.25 ± 0.96). "shoulder BMAC" and "shoulder bone marrow aspirate concentrate" were most difficult to read (mean = 12.54 ± 3.73). Sixty-four percent of websites were authored by physicians, hospitals, or medical groups. The accuracy of websites authored by health care professionals was significantly higher than the accuracy of those authored by other industry sources (P = .01). Fifteen percent of websites demonstrated commercial bias. Discussion: The online resources available to patients seeking information about biologic therapies for the treatment of shoulder pathologies are of very poor quality, moderately poor accuracy, and advanced readability. Providers should caution patients about the reliability of direct-to-consumer biologic marketing for shoulder pathology. Conclusion: The information available to patients online regarding the diagnosis, evaluation, and treatment of shoulder pathology with biologic therapies is of poor quality and accuracy and difficult readability.