One- and 2-Year American Shoulder and Elbow Surgeons Scores Do Not Vary Significantly After Arthroscopic Rotator Cuff Repair: A Prospective Multicenter Analysis of 1,567 Patients.

PURPOSE: To evaluate whether there are clinically significant changes in patient-reported outcomes between 1 and 2 years' postoperatively after arthroscopic rotator cuff repair (RCR). METHODS: A retrospective analysis of prospective, multicenter registry was queried for all patients who underwent RCR. Patients with preoperative, 6-month, 1-year, and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. We evaluated mean postoperative ASES scores, Δ (change from preoperative) ASES, and the %MOI (% maximum outcome improvement). We also evaluated achievement of clinically significant outcomes (CSOs) for the ASES score, including the minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state. RESULTS: There were 1,567 patients with complete data through 2-year follow-up. There were small differences in achievement of CSOs from 1 to 2 years: 88% to 91% for MCID, 81% to 83% for substantial clinical benefit, and 65% to 71% for patient-acceptable symptom state. There were statistically significant differences from 1 to 2 years in mean ASES (87 to 88, P < .001), Δ ASES (37 to 39, P < .001), and %MOI (72% to 76%, P < .001); however, these changes were well below the MCID of 11.1. From 1 to 2 years, the mean ASES improved only 1.7 points (P < .001). At 1 year, patients achieved, on average, 97% of their 2-year ASES. CONCLUSIONS: Both patient-reported outcomes and achievement of CSOs show small differences at 1 and 2 years after RCR. Given the large sample size, there were statistical differences, but these are unlikely to be clinically relevant. LEVEL OF EVIDENCE: Level IV, case series.

Acute, Traumatic Rotator Cuff Tears Have Smaller Critical Shoulder Angles Than Degenerative Tears.

PURPOSE: To determine whether the critical shoulder angle (CSA) in acute, traumatic rotator cuff tears (RCTs) is consistent with the previously described CSA in chronic degenerative RCTs. METHODS: We performed a multicenter retrospective analysis of 134 patients presenting to 5 surgeons fellowship trained in shoulder and elbow or sports. Preoperative imaging was used to measure the CSA and tear characteristics. Patients were included if they had acute, traumatic full-thickness RCTs documented on advanced imaging and had preoperative Grashey radiographs. Patients were excluded if they had any history of shoulder pain, injury, surgery, or treatment prior to the current episode; were overhead athletes; or had fatty infiltration greater than Goutallier grade 1 on imaging. RESULTS: The mean CSA was 33.5° (standard deviation, 4.1°), and 60% of tears had a CSA of less than 35°, much below the mean of 38.0° and the threshold of greater than 35° in degenerative RCTs. The mean age was 58 years, and 70% of patients were men. Overall, 60% of tears involved the subscapularis, 49% of tears occurred in patients aged 60 years or older, and 18% of patients sustained a dislocation. Older age (ß = 0.316, P = .003) and male sex (ß = 5.532, P = .025) were predictive of tear size, and older age (ß = 0.229, P = .011) and biceps avulsion (ß = 8.822, P = .012) were predictive of tear retraction. CONCLUSIONS: Acute, traumatic RCTs have CSAs that are 5° smaller than those of degenerative tears, and the majority (60%) have CSAs that are below the threshold consistent with degenerative RCTs. The majority of traumatic tears (60%) involve the subscapularis. CLINICAL RELEVANCE: The study findings suggest that a traumatic tear is not simply the acute failure of a degenerative tendon and that it represents a distinct pathologic entity. These findings support current practice of treating traumatic RCTs differently than degenerative RCTs.

Humeral offset as a predictor of outcomes after reverse shoulder arthroplasty.

INTRODUCTION: The Grammont-style reverse shoulder arthroplasty (RSA) relies on medialization and distalization of the shoulder center of rotation. Lateralized designs have recently gained popularity. The amount of lateralization, however, remains a controversial topic. The purpose of this study was to correlate the change in humeral offset (HO) with outcomes and complications following RSA. We hypothesized that a lateralized HO following RSA would be associated with improved range of motion (ROM), better patient-reported outcomes (PROs), and fewer complications. MATERIALS AND METHODS: A consecutive series of 104 patients (109 shoulders) was retrospectively evaluated. All patients underwent primary RSA by 2 shoulder and elbow fellowship-trained orthopedic surgeons at 2 different centers. Inclusion criteria was a primary RSA with at least 1-year follow-up. All patients had the HO measured on a preoperative and a postoperative Grashey radiograph, and the change in HO was calculated (ΔHO = PostHO-PreHO). A negative value was defined as a medialized HO and a positive value as a lateralized HO. ROM and primary outcomes, including forward elevation (FE), external rotation (ER), internal rotation (IR), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, were collected. Complications and revisions were also reported. RESULTS: The mean age was 72 years with a mean follow-up of 22.3 months. The average FE (92° vs. 148°), ER (34° vs. 44°), SSV (35% vs. 87%), and ASES score (37.2 vs. 81.2) increased significantly (all P < .01) compared with preoperative values. The HO was medialized postoperatively in 63 shoulders and lateralized in 46 shoulders. No statistically significant differences in the mean values for postoperative FE (147° vs. 146°, P = .892), ER (43° vs. 45°, P = .582), IR (L3 vs. L3, P = .852), SSV (88% vs. 85%, P = .476), and ASES score (81.3 vs. 81.1, P = .961) were found between the groups. However, there was significantly more improvement in ER in the lateralized HO cohort than the medialized cohort (16° vs. 7°, P = .033). Six shoulders, 5 medialized and 1 lateralized HO, demonstrated scapular notching and remained asymptomatic. Five shoulders, 4 medialized and 1 lateralized HO, experienced at least 1 instability incident, and 2 shoulders with medialized HO had an acromion/scapular spine fracture. Overall, 2 shoulders with medialized HO underwent revision surgery because of instability. CONCLUSIONS: Although RSA provides significant improvement in ROM and PROs regardless of postoperative HO, restoring baseline HO or lateralization beyond baseline may be favorable for improving ER and decreasing complications following RSA.

Reliability testing of two classification systems for osteoarthritis and post-traumatic arthritis of the elbow.

HYPOTHESIS AND BACKGROUND: The severity of elbow arthritis is one of many factors that surgeons must evaluate when considering treatment options for a given patient. Elbow surgeons have historically used the Broberg and Morrey (BM) and Hastings and Rettig (HR) classification systems to radiographically stage the severity of post-traumatic arthritis (PTA) and primary osteoarthritis (OA). We proposed to compare the intraobserver and interobserver reliability between systems for patients with either PTA or OA. METHODS: The radiographs of 45 patients were evaluated at least 2 weeks apart by 6 evaluators of different levels of training. Intraobserver and interobserver reliability were calculated by Spearman correlation coefficients with 95% confidence intervals. Agreement was considered almost perfect for coefficients >0.80 and substantial for coefficients of 0.61 to 0.80. RESULTS: In patients with both PTA and OA, intraobserver reliability and interobserver reliability were substantial, with no difference between classification systems. There were no significant differences in intraobserver or interobserver reliability between attending physicians and trainees for either classification system (all P > .10). The presence of fracture implants did not affect reliability in the BM system but did substantially worsen reliability in the HR system (intraobserver P = .04 and interobserver P = .001). CONCLUSIONS: The BM and HR classifications both showed substantial intraobserver and interobserver reliability for PTA and OA. Training level differences did not affect reliability for either system. Both trainees and fellowship-trained surgeons may easily and reliably apply each classification system to the evaluation of primary elbow OA and PTA, although the HR system was less reliable in the presence of fracture implants.

Preoperative tendon retraction, not smoking, is a risk factor for failure with continuity after rotator cuff repair.

BACKGROUND: Smoking is a poor prognostic factor for healing after rotator cuff repair and is associated with inferior results. We hypothesized that smokers would have higher recurrent tear rates and more postoperative myotendinous junction (MTJ) retraction in healed repairs than nonsmokers three months postoperatively. METHODS: Rotator cuff repairs (RCRs) were retrospectively reviewed over a 2-year period. Patients underwent magnetic resonance imaging (MRI) within 6 months prior to surgery and again at 3 months postoperatively. Seventy-nine patients were included and stratified by smokers versus nonsmokers. Baseline patient demographics, tear characteristics, and surgical factors were collected. Preoperative and postoperative MRIs were assessed to quantify the MTJ position and to establish the recurrent tear rate. RESULTS: For the total cohort (nonsmokers, n = 56; smokers, n = 23), significant differences in age, race, and traumatic onset of injury existed between groups. There were no significant differences in recurrent tear between smokers (26%) and nonsmokers (27%), but nonsmokers were more satisfied. For patients with healed RCRs (nonsmokers, n = 41; smokers, n = 17), there were significant differences in race. On univariate analysis, nonsmokers had a significantly more lateral MTJ postoperatively (P = 0.05). On multivariable regression analysis, medialized postoperative MTJ position in healed cuffs was driven only by greater preoperative rotator cuff retraction preoperatively. There were no significant differences in MTJ position based on smoking status for patients with healed RCRs. CONCLUSION: Smoking does not appear to be an independent risk factor for postoperative MTJ retraction in healed RCRs, also known as failure in continuity. Preoperative tear size and retraction play the biggest roles in predicting postoperative MTJ position, regardless of smoking status. There are no significant differences in patient-reported outcomes for patients with healed RCRs, but nonsmokers had more satisfaction following RCR in the total cohort. LEVEL OF EVIDENCE: Level III; Retrospective cohort study; Diagnostic study.

Extracellular heat shock cognate protein 70 induces cardiac functional tolerance to endotoxin: differential effect on TNF-alpha and ICAM-1 levels in heart tissue.

Endotoxin provokes cardiac dysfunction, and induction of tolerance to endotoxin has therapeutic potential. Heat shock protein 70 (HSP70) can induce endotoxin tolerance in macrophages. We recently found that heat shock cognate protein 70 (HSC70) induces pro-inflammatory cytokines via activation of TLR4 in macrophages and the myocardium. We hypothesize that HSC70 preconditioning induces cardiac tolerance to endotoxin. Pretreatment of peritoneal macrophages with HSC70 for 24h reduced TNF-alpha levels following endotoxin stimulation. Preconditioning of mice with HSC70 24h prior to endotoxin attenuated endotoxemic cardiac dysfunction. HSC70 preconditioning reduced TNF-alpha levels in plasma and heart tissue by 33.3% and 35.4%, respectively, and decreased ICAM-1 levels in heart tissue by 63.5% following endotoxin challenge. The effect of HSC70 on TNF-alpha was less robust than endotoxin preconditioning (79.7% and 75.0% reduction in TNF-alpha levels in plasma and heart tissue, respectively); however, HSC70 and endotoxin preconditioning had comparable effects on ICAM-1 levels in heart tissue. While HSC70 preconditioning had no effect on myocardial TLR4 protein levels, it suppressed NF-kappaB activation induced by endotoxin. We conclude that HSC70 preconditioning (1) attenuates the TNF-alpha response to endotoxin in macrophages in vitro, (2) induces cardiac functional tolerance to endotoxin and (3) reduces NF-kappaB activity, and TNF-alpha and ICAM-1 levels in heart tissue. Thus, the mechanism of HSC70-induced cardiac tolerance to endotoxin appears to involve down-regulation of myocardial TLR4 signaling and inflammatory responses.