Diagnostic utility of different types of somatosensory evoked potential changes in pediatric idiopathic scoliosis correction surgery.

PURPOSE: To evaluate the diagnostic accuracy of intraoperative somatosensory evoked potential (SSEP) monitoring and types of SSEP changes in predicting the risk of postoperative neurological outcomes during correction surgery for idiopathic scoliosis (IS) in the pediatric age group (≤ 21 years). METHODS: Database review was performed to identify literature on pediatric patients with IS who underwent correction with intraoperative neuromonitoring. The sensitivity, specificity, and diagnostic odds ratio (DOR) of transient and persistent SSEP changes and complete SSEP loss in predicting postoperative neurological deficits were calculated. RESULTS: Final analysis included 3778 patients. SSEP changes had a sensitivity of 72.9%, specificity of 96.8%, and DOR of 102.3, while SSEP loss had a sensitivity of 41.8%, specificity of 99.3%, and DOR of 133.2 for predicting new neurologic deficits. Transient and persistent SSEP changes had specificities of 96.8% and 99.1%, and DORs of 16.6 and 59, respectively. CONCLUSION: Intraoperative SSEP monitoring can predict perioperative neurological injury and improve surgical outcomes in pediatric scoliosis fusion surgery. LEVEL OF EVIDENCE: Level 2. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Magnetic Resonance Arthrogram Outperforms Standard Magnetic Resonance Imaging 2 Weeks After First Shoulder Dislocation for Labral Tear Diagnosis.

PURPOSE: To determine the comparative accuracy and precision of routine magnetic resonance imaging (MRI) versus magnetic resonance (MR) arthrogram in measuring labral tear size as a function of time from a shoulder dislocation. METHODS: We retrospectively evaluated consecutive patients who underwent primary arthroscopic stabilization between 2012 and 2021 in a single academic center. All patients completed a preoperative MRI or MR arthrogram of the shoulder within 60 days of injury and subsequently underwent arthroscopic repair within 6 months of imaging. Intraoperative labral tear size and location were used as standards for comparison. Three musculoskeletal radiologists independently interpreted tear extent using a clock-face convention. Accuracy and precision of MR labral tear measurements were defined based on location and size of the tear, respectively. Accuracy and precision were compared between MRI and MR arthrogram as a function of time from dislocation. RESULTS: In total, 32 MRIs and 65 MR arthrograms (total n = 97) were assessed. Multivariate analysis demonstrated that intraoperative tear size, early imaging, and arthrogram status were associated with increased MR accuracy and precision (P < .05). Ordering surgeons preferred arthrogram for delayed imaging (P = .018). For routine MRI, error in accuracy increased by 3.4° per day and error in precision increased by 2.3° per day (P < .001) from time of injury. MR arthrogram, however, was not temporally influenced. Significant loss of accuracy and precision of MRI compared with MR arthrogram occurred at 2 weeks after an acute shoulder dislocation. CONCLUSIONS: Compared with MR arthrogram, conventional MRI demonstrates time-dependent loss of accuracy and precision in determining shoulder labral tear extent after dislocation, with statistical divergence occurring at 2 weeks. LEVEL OF EVIDENCE: Level II, retrospective radiographic diagnostic study.

Posterior Glenoid Bone Block Reconstruction: Indications, Techniques, and Outcomes.

Posterior shoulder instability is of particular therapeutic interest, as it typically affects patients with high functional demands such as young athletes and active adults. Although posterior capsulolabral repair has high return-to-sport rates, it is associated with recurrent instability of up to 11%. Posterior glenoid bone loss and significant glenoid retroversion have been identified as risk factors for recurrent instability and failure after primary arthroscopic soft-tissue repair. Therefore, posterior glenoid bone block reconstruction may be indicated for glenoid bone loss 20% or greater (as measured by the perfect circle technique) or greater than 10% in the setting of pathologic glenoid, failed primary posterior labral repair, incompetent posterior capsular tissue, or significant risk factors for failure of soft-tissue repair. This procedure may be performed arthroscopically or with a posterior open approach using distal tibial allograft, iliac crest autograft, or scapular spine autograft. Although short-term to midterm outcomes have been promising, there remain concerns regarding long-term outcomes, with potentially high rates of late recurrence, revision, and secondary osteoarthritis.

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) has been increasingly utilized for a variety of shoulder pathologies that are difficult to treat with anatomical total shoulder arthroplasty (TSA). Few studies have compared the outcomes of TSA vs. RSA in patients with cuff intact glenohumeral osteoarthritis and poor preoperative forward elevation. This study aimed to determine whether there is a difference in functional outcomes and postoperative range of motion (ROM) between TSA and RSA in these patients. METHODS: This retrospective cohort study included 116 patients who underwent RSA or TSA between 2013 and 2022 for the treatment of rotator cuff intact primary osteoarthritis with restricted preoperative forward flexion (FF) and a minimum 1-year follow-up. Each arthroplasty group was divided into 2 subgroups: patients with preoperative FF between 91° and 120° or FF lower than or equal to 90°. Patients' clinical outcomes, including active ROM, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective shoulder value were collected. Clinical and radiographic complications were evaluated. RESULTS: There was no significant difference between RSA and TSA in terms of sex (58.3% male vs. 62.2% male, P = .692), or follow-up duration (20.1 months vs. 17.7 months, P = .230). However, the RSA cohort was significantly older (72.0 ± 8.2 vs. 65.4 ± 10.6, P = .012) and weaker in FF and (ER) before surgery (P < .001). There was no difference between RSA (57 patients) and TSA (59 patients) in visual analog scale pain score (1.2 ± 2.3 vs. 1.3 ± 2.3, P = .925), subjective shoulder value score (90 ± 15 vs. 90 ± 15, P = .859), or American Shoulder and Elbow Surgeons score (78.4 ± 20.5 vs. 82.1 ± 23.2, P = .476). Postoperative active ROM was statistically similar between RSA and TSA cohorts in FF (145 ± 26 vs. 146 ± 23, P = .728) and ER (39 ± 15 vs. 41 ± 15, P = .584). However, internal rotation was lower in the RSA cohort (P < .001). This was also true in each subgroup. RSA led to faster postoperative FF and ER achievement at 3 months (P < .001). There was no statistically significant difference in complication rates between cohorts. CONCLUSION: This study demonstrates that patients with glenohumeral osteoarthritis who have a structurally intact rotator cuff but limited preoperative forward elevation can achieve predictable clinical improvement in pain, ROM, and function after either TSA or RSA. Reverse arthroplasty may be a reliable treatment option in patients at risk for developing rotator cuff failure.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors.

BACKGROUND: The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°). METHODS: This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis. RESULTS: There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis. CONCLUSIONS: In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

Arthroscopic Bankart Repair with Remplissage Yields Similar Outcomes to Open Latarjet for Primary and Revision Stabilization in The Setting of Subcritical Glenoid Bone Loss.

BACKGROUND: Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR+R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR+R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings. METHODS: A retrospective study was conducted on patients undergoing either arthroscopic ABR+R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), < 2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value (SSV), strength and range of motion (ROM) RESULTS: 108 patients (70 ABR+R, 38 Latarjet) were included with an average follow-up of 4.3 ±2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: p=0.60; Revision: p=0.28) and reoperation (Primary: p=0.06; Revision: p=1.00) were observed between Latarjet and ABR+R. Primary ABR+R exhibited better SSV, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting. CONCLUSION: Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR+R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR+R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Preoperative factors associated with 180°, 270°, and 360° labral tears.

BACKGROUND: Large, circumferential glenoid labral tears are an uncommon injury affecting young, athletic patients. There are limited data describing the clinical presentation of patients with larger tears, especially 270° and 360° labral tears. Additionally, examination and imaging findings have poor reliability in diagnosing these tears. The purpose of this study was to determine the clinical presentation among patients presenting with small (less than 180°), medium (180°-270°), and large (270°-360°) labral tears. METHODS: This is a retrospective comparative study of consecutive patients surgically managed by a single shoulder surgeon for all glenoid labral tears from 2018-2022. The primary outcome was demographic and preoperative clinical risk factors. Demographic data including age, sex, hand dominance, body mass index, as well as clinical presentation (subluxation vs. dislocation, instability history, and participation in contact sports) were recorded. RESULTS: A total of 188 patients met the inclusion criteria: 101 of 188 (53.70%) patients with small tears, 43 of 188 (22.90%) patients with medium tears, and 44 of 188 (23.40%) patients with large tears. Individuals with large and medium-sized labral tears were more likely to have participated in contact sports compared to those with smaller labral tears (P = .003). Medium and smaller tears were more likely to present as dominant-side injury (P = .02). Furthermore, medium and large tears were more likely to present with anterior instability symptoms compared with smaller tears, which more frequently presented with posterior instability and pain (P = .003). CONCLUSION: Males participating in contact sports were the most common demographic population presenting with large, 270°-360° labral tears. Instability was the primary complaint rather than pain, and compared with small tears, medium and large tears were more likely to present with primary anterior instability. Although arthroscopic repair of 270°-360° labral tears can yield excellent clinical outcomes similar to smaller tears, identifying factors associated with larger glenoid labral tears may help in surgical planning and patient counseling.

Margin convergence vs. superior capsular reconstruction for massive irreparable rotator cuff tears: outcomes are equivalent unless there is preoperative pseudoparesis.

BACKGROUND: Margin convergence (MC) and superior capsular reconstruction (SCR) are common treatment options for irreparable rotator cuff tears in younger patients, although they differ in associated costs and operative times. The purpose of this study was to compare range of motion, patient-reported outcomes (PROs), and reoperation rates following MC and SCR. We hypothesized superior outcomes after SCR relative to MC regarding functional outcomes, subjective measures, and reoperation rates. METHODS: This was a multicenter retrospective review of 59 patients from 3 surgeons treating irreparable rotator cuff tears with either MC (n = 28) or SCR (n = 31) and minimum 1-year follow-up from 2014-2019. Visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), active forward flexion (FF), external rotation (ER), retear rate, and conversion rate to reverse shoulder arthroplasty were evaluated. t tests and χ2 tests were used for continuous and categorical variables, respectively (P < .05). RESULTS: Baseline demographics, range of motion, and magnetic resonance imaging findings were similar between groups. Average follow-up was 31.5 months and 17.8 months for the MC and SCR groups, respectively (P < .001). The MC and SCR groups had similar postoperative FF (151° ± 26° vs. 142° ± 38°; P = .325) and ER (48° ± 12° vs. 46° ± 11°; P = .284), with both groups not improving significantly from their preoperative baselines. However, both cohorts demonstrated significant improvements in VAS score (MC: 7.3 to 2.5; SCR: 6.4 to 1.0) and SSV (MC: 54% to 82%; SCR: 38% to 87%). There were no significant differences in postoperative VAS scores, SSV, and rates of retear or rates of conversion to arthroplasty between the MC and SCR groups. In patients with preoperative pseudoparesis (FF < 90°), SCR (n = 9) resulted in greater postoperative FF than MC (n = 5) (141° ± 38° vs. 67° ± 24°; P = .002). CONCLUSION: Both MC and SCR demonstrated excellent postoperative outcomes in the setting of massive irreparable rotator cuff tear, with significant improvements in PROs and no significant differences in range of motion. Specifically for patients with preoperative pseudoparesis, SCR was more effective in restoring forward elevation. Further long-term studies are needed to compare outcomes and establish appropriate indications.

Reversing chronic pseudoparesis secondary to massive, irreparable rotator cuff tear: superior capsular reconstruction vs. reverse total shoulder arthroplasty.

INTRODUCTION: Recent studies have defined pseudoparesis as limited active forward elevation between 45° and 90° and maintained passive range of motion (ROM) in the setting of a massive rotator cuff tear (RCT). Although pseudoparesis can be reliably reversed with reverse total shoulder arthroplasty (RSA) or superior capsular reconstruction (SCR), the optimal treatment for this indication remains unknown. The purpose of this study was to compare the clinical outcomes of RSA to SCR in patients with pseudoparesis secondary to massive, irreparable RCT (miRCT). METHODS: This was a retrospective cohort study of consecutive patients aged 40-70 years with pseudoparesis secondary to miRCT who were treated with either RSA or SCR by a single fellowship-trained shoulder surgeon from 2016 to 2021 with a minimum 12-month follow-up. Multivariate linear regression modeling was used to compare active ROM, visual analog pain scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score between RSA and SCR while controlling for confounding variables. RESULTS: Twenty-seven patients were included in the RSA cohort and 23 patients were included in the SCR cohort with similar mean follow-up times (26.2 ± 21.1 vs. 21.9 ± 14.7 months, respectively). The patients in the RSA group were significantly older than those in the SCR group (65.2 ± 4.4 vs. 54.2 ± 7.8 years, P < .001) and had more severe arthritis (1.8 ± 0.9 vs. 1.2 ± 0.5 Samilson-Prieto, P = .019). The pseudoparesis reversal rate among the RSA and SCR cohorts was 96.3% and 91.3%, respectively. On univariate analysis, the RSA cohort demonstrated significantly greater mean improvement in active FF (89° ± 26° vs. 73° ± 30° change, P = .048), greater postoperative SSV (91 ± 8% vs. 69 ± 25%, P < .001), lower postoperative VAS pain scores (0.6 ± 1.2 vs. 2.2 ± 2.9, P = .020), and less postoperative internal rotation (IR; 4.6° ± 1.6° vs. 6.9° ± 1.8°, P = .004) compared with SCR. On multivariate analysis controlling for age and osteoarthritis, RSA remained a significant predictor of greater SSV (ß = 21.5, P = .021) and lower VAS scores (ß = -1.4, P = .037), whereas SCR was predictive of greater IR ROM (ß = 3.0, P = .043). CONCLUSION: Although both RSA and SCR effectively reverse pseudoparesis, patients with RSA have higher SSV and lower pain scores but less IR after controlling for age and osteoarthritis. The results of this study may inform surgical decision making for patients who are suitable candidates for either procedure.

Utility of transcranial motor-evoked potential changes in predicting postoperative deficit in lumbar decompression and fusion surgery: a systematic review and meta-analysis.

PURPOSE: The primary aim of this study was to evaluate whether TcMEP alarms can predict the occurrence of postoperative neurological deficit in patients undergoing lumbar spine surgery. The secondary aim was to determine whether the various types of TcMEP alarms including transient and persistent changes portend varying degrees of injury risk. METHODS: This was a systematic review and meta-analysis of the literature from PubMed, Web of Science, and Embase regarding outcomes of transcranial motor-evoked potential (TcMEP) monitoring during lumbar decompression and fusion surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR) of TcMEP alarms for predicting postoperative deficit were calculated and presented with forest plots and a summary receiver operating characteristic curve. RESULTS: Eight studies were included, consisting of 4923 patients. The incidence of postoperative neurological deficit was 0.73% (36/4923). The incidence of deficits in patients with significant TcMEP changes was 11.79% (27/229), while the incidence in those without changes was 0.19% (9/4694). All TcMEP alarms had a pooled sensitivity and specificity of 63 and 95% with a DOR of 34.92 (95% CI 7.95-153.42). Transient and persistent changes had sensitivities of 29% and 47%, specificities of 96% and 98%, and DORs of 8.04 and 66.06, respectively. CONCLUSION: TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in lumbar decompression and fusion surgery. Patients who awoke with new postoperative deficits were 35 times more likely to have experienced TcMEP changes intraoperatively, with persistent changes indicating higher risk of deficit than transient changes. LEVEL OF EVIDENCE II: Diagnostic Systematic Review.

Outpatient shoulder arthroplasty in the COVID-19 era: 90-day complications and risk factors.

BACKGROUND: With the COVID-19 pandemic placing an increased burden on health care systems, shoulder arthroplasties are more commonly being performed as outpatient procedures. The purpose of this study was to characterize the 90-day episode-of-care complications of consecutive shoulder arthroplasties defaulted for outpatient surgery without using a prior algorithm for patient selection and to assess for their risk factors. We hypothesized that outpatient shoulder arthroplasty would be a safe procedure for all patients, regardless of patient demographics and comorbidities. METHODS: A retrospective review of consecutive patients who underwent planned outpatient anatomic or reverse total shoulder arthroplasty between March 2020 and January 2022 with 3-month follow-up was performed. All patients were scheduled for outpatient surgery regardless of medical comorbidities. Patient demographics; pre/postoperative patient-reported outcomes including visual analog scale, subjective shoulder value, and American Shoulder and Elbow Surgeons score; pre/postoperative range of motion; and complications were collected from medical chart review. Multivariate logistic regression was used to identify predictors of the following outcomes: 1. Unplanned overnight hospital stay, 2. 90-day unplanned emergency department (ED)/clinic visit, 3. 90-day hospital readmission, 4. 90-day complications requiring revision. RESULTS: One hundred twenty-seven patients (47% male, 17% tobacco users, 18% diabetics) with a mean age 69 ± 9 years were identified, of whom 92 underwent reverse total shoulder arthroplasty and 35 underwent anatomic total shoulder arthroplasty. All patient-reported outcomes and range of motion were significantly improved at 3 months. There were 15 unplanned overnight hospital stays (11.8%) after the procedure. Within 90 days postoperatively, there were 17 unplanned ED/clinic visits (13.4%), 7 hospital readmissions (5.5%), and 4 complications requiring revision (3.1%). Factors predictive of unplanned overnight stay included age above 70 years (odds ratio [OR], 36.80 [95% confidence interval [CI], 2.20-615.49]; P = .012), tobacco use (OR, 12.90 [95% CI, 1.23-135.31]; P = .033), and American Society of Anesthesiologists status of 3 (OR, 13.84 [95% CI, 1.22-156.57]; P = .034). The only factor predictive of unplanned ED/clinic visit was age over 70 years old (OR, 7.52 [95% CI, 1.26-45.45]; P = .027). No factors were predictive of 90-day hospital readmission or revision. CONCLUSION: Outpatient shoulder arthroplasty is a safe procedure with excellent outcomes and low rates of readmissions and can be considered as the default plan for all patient undergoing shoulder arthroplasty. Patients who are above 70 years of age, use tobacco, and have ASA score of 3, however, may be less suitable for outpatient arthroplasty and should be counseled regarding the higher risk of unplanned overnight hospitalization.

Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy.

INTRODUCTION: Indications for reverse total shoulder arthroplasty (RSA) have expanded to include individuals with intact rotator cuffs such as patients with severe glenoid deformity or with concern of future rotator cuff insufficiency. The purpose of this study was to compare outcomes of RSA with an intact rotator cuff to RSA for cuff arthropathy and anatomic total shoulder arthroplasty (TSA). We hypothesized that outcomes of RSA with an intact rotator cuff would be comparable to RSA for cuff arthropathy and TSA but with diminished range of motion (ROM) compared with TSA. MATERIALS AND METHODS: Patients at one institution who underwent RSA and TSA between 2015 and 2020 with minimum 12-month follow-up were identified. RSA with preservation of the rotator cuff (+rcRSA) was compared to RSA for cuff arthropathy (-rcRSA) and anatomic TSA (TSA). Demographics and glenoid version/inclination were obtained. Pre- and postoperative ROM; patient-reported outcomes including visual analog scale (VAS), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores; and complications were obtained. RESULTS: Twenty-four patients underwent +rcRSA, 69 underwent -rcRSA, and 93 underwent TSA. There were more women in the +rcRSA cohort (75.8%) than in the -rcRSA (37.7%, P = .001) and TSA (37.6%, P = .001) cohorts. Mean age of the +rcRSA cohort (71.1) was greater than that of TSA (66.0, P = .021) but similar to that of -rcRSA (72.4, P = .237). Glenoid retroversion was greater in +rcRSA (18.2°) compared with -rcRSA (10.5°, P = .011) but was similar to TSA (14.7°; P = .244). Postoperatively, there were no differences in VAS or ASES between +rcRSA vs. -rcRSA and +rcRSA vs. TSA. SSV was lower in +rcRSA (83.9) compared with -rcRSA (91.8, P = .021), but was similar to TSA (90.5, P = .073). Similar ROM was achieved in forward flexion, external rotation, and internal rotation at final follow-up between +rcRSA and -rcRSA, but TSA had greater external rotation (44° vs. 38°, P = .041) and internal rotation (6.5° vs. 5.0°, P = .001) compared with +rcRSA. There were no differences in complication rates. DISCUSSION: At short-term follow-up, preservation of the rotator cuff in RSA demonstrated similarly excellent outcomes and low complication rates compared with RSA with a deficient rotator cuff and TSA, except for slightly lower internal and external rotation compared with TSA. Although multiple factors deserve consideration when choosing between RSA and TSA, RSA with preservation of the posterosuperior cuff is a viable treatment option for glenohumeral osteoarthritis, particularly in patients with severe glenoid deformity or those at risk for future rotator cuff insufficiency.

Traumatic rotator cuff tears with concomitant shoulder dislocation: tear characteristics and postsurgical outcomes.

BACKGROUND: Arthroscopic rotator cuff repair has been shown to have favorable outcomes following traumatic rotator cuff tear with concomitant shoulder dislocation. The aim of this study was to compare outcomes and tear characteristics between patients who underwent arthroscopic rotator cuff repair following traumatic tear with shoulder dislocation to those without dislocation. METHODS: A retrospective review of 226 consecutive patients with traumatic rotator cuff tears who underwent arthroscopic repair between 2013 and 2017 with a minimum of 1-year follow-up was performed. Patients with traumatic dislocations and concomitant rotator cuff tears were placed in the Dislocation & Tear cohort (DT cohort) and were matched 1:2 with a second cohort sustaining traumatic cuff tears without dislocation (T cohort). Primary outcomes were injury characteristics including tendon involvement and atrophy and tear size and thickness. Secondary outcomes were postoperative strength and range of motion (ROM) in forward flexion (FF), external rotation (ER), and internal rotation (IR); patient-reported outcomes including Subjective Shoulder Value, visual analog scale, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form; complications including repair failure (defined as symptomatic retear confirmed on postoperative magnetic resonance imaging), infection, adhesive capsulitis, and impingement; and rates of revision surgery. RESULTS: There were 18 patients in the DT Cohort and 36 patients in the T Cohort with no significant differences in time to final follow-up (50.4 ± 24.5 months vs. 49.0 ± 30.4 months, P = .73). The DT cohort displayed a larger mean tear size (34 ± 12 mm vs. 19 ± 12 mm, P = .01) and had greater infraspinatus involvement (78% vs. 36%, P = .004) and subscapularis involvement (72% vs. 39%, P = .02) than the T cohort. With regard to strength, postoperative ER strength was less likely to be 5/5 in the DT Cohort (53% vs. 94% of patients with 5/5 strength, P = .002) compared with the T cohort. With regard to ROM, the DT cohort had significantly lower preoperative FF (90° ± 55° vs. 149° ± 33°, P < .001), ER (36 ± 21° vs. 52° ± 14°, P = .02), and IR (5.4 ± 2.1 vs. 7.5 ± 1.2, P = .002) compared with the T cohort but had similar FF, ER, and IR outcomes postoperatively. There were no differences between the groups for complications and postoperative patient-reported outcomes. CONCLUSION: Traumatic rotator cuff tears with concomitant dislocations are associated with larger tear size and greater infraspinatus and subscapularis involvement than traumatic tears without dislocation. Arthroscopic repair of this injury is associated with lower preoperative ROM in FF, ER, and IR, as well as lower postoperative ER strength compared with traumatic tears without dislocation. Nonetheless, excellent patient-reported outcomes can be achieved following arthroscopic repair similar to patients without dislocation.

Clinical outcomes of rotator cuff repair in patients with concomitant glenohumeral osteoarthritis.

BACKGROUND: Glenohumeral osteoarthritis (OA) is a common comorbidity in patients with rotator cuff tears. However, the efficacy of rotator cuff repair in patients with concomitant glenohumeral OA is still heavily debated. Thus, the purpose of this study was to compare the clinical and functional outcome measures following arthroscopic rotator cuff repairs in patients with concomitant glenohumeral OA vs. those without glenohumeral OA. METHODS: A retrospective review of 206 consecutive patients who underwent arthroscopic supraspinatus repairs (both isolated and with accompanying infraspinatus and/or subscapularis involvement) between 2013 and 2018 with a minimum of 1-year follow-up was performed. Patients were separated into 2 groups based on the presence or absence of concomitant glenohumeral OA. The primary outcome was failure of repair, defined as the need for revision repair or a retear confirmed on postoperative magnetic resonance imaging. The secondary outcomes were patient-reported outcome measures including the visual analog scale pain score, Subjective Shoulder Value, and American Shoulder and Elbow Surgeons score; active range of motion (ROM); and strength testing. Within the OA cohort, a subgroup analysis was conducted to compare outcomes between patients with mild OA and patients with moderate to severe OA. RESULTS: There were 91 patients in the glenohumeral OA group and 115 patients in the control group. Significant differences in postoperative forward flexion (FF) ROM (153.55° ± 21.07° vs. 160.14° ± 17.26°, P = .001) and external rotation (ER) ROM (46.91° ± 11.95° vs. 52.25° ± 11.60°, P = .001) were observed between the glenohumeral OA and control groups. There were no significant differences between groups in revision repairs, retears, postoperative internal rotation ROM, all preoperative ROMs, all patient-reported outcome measures, and all strength parameters (all P > .05). For the subgroup analysis, there were 70 patients in the mild OA group and 21 patients in the moderate to severe OA group. We found a significant difference in postoperative FF strength (88.4% vs. 61.9% with 5 of 5 strength, P = .010) and ER strength (89.9% vs. 71.4% with 5 of 5 strength, P = .046) between the mild OA group and moderate to severe OA group. There were no significant differences between the groups in all other outcome measures. DISCUSSION: Rotator cuff repair remains an excellent treatment option in patients with concomitant glenohumeral OA. The data in this study demonstrate that rotator cuff repairs in patients with concomitant glenohumeral OA have similar clinical and functional outcomes to repairs in patients without OA with the exception of slightly decreased postoperative FF and ER ROM. Patients with moderate to severe OA may have slightly decreased FF and ER strength outcomes compared with patients with mild OA.

Thread Delamination in 4.5 mm AO Cannulated Screws: A Small Case Series in the Pediatric Trauma Population.

BACKGROUND: Thread delamination associated with cannulated screws have been reported but likely represent an under-recognized complication in the orthopaedic literature. The purpose of this study is to report the occurrence of repeated hardware failures through thread delamination in the setting of a commonly used orthopaedic cannulated screw implant in a small cohort involving pediatric fracture care at a single academic level I trauma center. METHODS: Between August 2015 and December 2020, 9 cases of hardware failure associated with 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated stainless-steel screws were identified within a pediatric orthopaedic division at a single academic level I trauma center. Three cases were excluded, and 6 cases of thread delamination were retrospectively reviewed. RESULTS: Six cases of thread delamination comprised a cohort of patients with a mean age of 13.7 years (range: 12 to 15 y). All cases involved 4.5 mm arbeitsgemeinschaft für osteosynthesefragen cannulated screws, including 5 partially threaded and 1 fully threaded screw. Five cases involved open reduction and internal fixation of incarcerated medial humeral epicondylar fragments and the other case was an open reduction and internal fixation of a displaced medial malleolar fracture. Five of these occurred within a recent 18-month period of time. There were 4 cases of partial, distal thread delamination, 1 case of partial proximal thread delamination and another case of complete thread delamination which had unwound into the tibiotalar joint and required an anterior ankle arthrotomy to retrieve the thread. None of the 5 patients in this series who currently harbor a retained thread have experienced symptoms because of this issue. CONCLUSIONS: Thread delamination associated with cannulated screw implantation likely represents an under-reported phenomenon in orthopaedic surgery. In cases where retained, delaminated threads exist, these do not appear to cause short-term concern. LEVEL OF EVIDENCE: Level IV-case series.

Repair of high-grade partial thickness supraspinatus tears after surgical completion of the tear have a lower retear rate when compared to full-thickness tear repair.

PURPOSE: High-grade partial thickness rotator cuff tears (i.e., those involving at least 50% of the tendon thickness) are especially challenging to treat and various treatment strategies have been described. Prior studies have demonstrated equivalent outcomes between in situ tear fixation and tear completion repair techniques. However, it is unknown how repair of completed high-grade partial thickness tears to full tears compares to repair of full-thickness tears. The purpose of this study was to compare clinical outcome measures at least 1 year postoperatively between patients who had completion of a high-grade partial thickness supraspinatus tear to a full-thickness tear (PT) and those who had an isolated full-thickness supraspinatus tear (FT). The hypothesis of this study was equivalent retear rates as well as equivalent clinical and patient-reported outcomes between the two groups. METHODS: A retrospective review of 100 patients who underwent isolated arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of 1 year follow-up was performed. Patients were separated into two groups based on their treatment: 56 had completion of a partial thickness supraspinatus tear to full-thickness tear with repair (PT) and 44 had isolated full-thickness supraspinatus repairs (FT). The primary outcome was rotator cuff retear, which was defined as a supraspinatus retear requiring revision repair. Secondary outcomes were patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV), range of motion (ROM) and strength in forward flexion (FF), external rotation (ER), and internal rotation (IR). RESULTS: There was a significantly lower rate of retear between the PT versus FT groups (3.6% vs. 16.3%, p = 0.040). There were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all n.s.). DISCUSSION: The data from this study demonstrated that the PT group had a significantly lower retear rate at 1 year follow-up than the FT group, while PROs, ROM, and strength were similar between the two groups. Patients with PT supraspinatus tears can have excellent outcomes, equivalent to FT tears, after completion of the tear, and subsequent repair with low retear rates. These findings may aid the treating surgeon when choosing between in situ fixation of the PT supraspinatus tear or completion of the tear and subsequent repair, as it allows the treating surgeon to choose the procedure based on comfort and experience level. LEVEL OF EVIDENCE: Level III.

Current Practices for Rehabilitation After Meniscus Repair: A Survey of Members of the American Orthopaedic Society for Sports Medicine.

Background: There is no consensus among sports medicine surgeons in North America on postoperative rehabilitation strategy after meniscus repair. Various meniscal tear types may necessitate a unique range of motion (ROM) and weightbearing rehabilitation protocol. Purpose: To assess the current landscape of how sports medicine practitioners in the American Orthopedic Society for Sports Medicine (AOSSM) rehabilitate patients after the repair of varying meniscal tears. Study Design: Cross-sectional study. Methods: A survey was distributed to 2973 AOSSM members by email. Participants reviewed arthroscopic images and brief patient history from 6 deidentified cases of meniscus repair-in cases 1 to 3, the tears retained hoop integrity (more stable repair), and in cases 4 to 6, the tear patterns represented a loss of hoop integrity. Cases were shuffled before the presentation. For each case, providers were asked at what postoperative time point they would permit (1) partial weightbearing (PWB), (2) full weightbearing (FWB), (3) full ROM, and (4) ROM allowed immediately after surgery. Results: In total, 451 surveys were completed (15.2% response). The times to PWB and FWB in cases 1 to 3 (median, 0 and 4 weeks, respectively) were significantly lower than those in cases 4 to 6 (median, 4 and 6 weeks, respectively) (P < .001). In tears with retained hoop integrity, the median time to PWB was immediately after surgery, whereas in tears without hoop integrity, the median time to PWB was at 4 weeks postoperatively. Similarly, the median time to FWB in each tear with retained hoop integrity was 4 weeks after surgery, while it was 6 weeks in each tear without hoop integrity. However, regardless of tear type, most providers (67.1%) allowed 0° to 90° of ROM immediately after surgery and allowed full ROM at 6 weeks. Most providers (83.3%) braced the knee after repair regardless of hoop integrity and utilized synovial rasping/trephination with notch microfracture-a much lower proportion of providers utilized biologic augmentation (9%). Conclusion: Sports medicine practitioners in the AOSSM rehabilitated meniscal tears differently based on hoop integrity, with loss of hoop stresses triggering a more conservative approach. A majority braced and utilized in situ adjuncts for biological healing, while a minority added extrinsic biologics.

The Effect of Timing Between Traumatic Flexor Tendon Injury of the Hand and Surgical Intervention on Repair Failure Rates.

Flexor tendon injuries of the hand, especially in zone II, pose a challenge for hand surgeons because of the region's intricate pulley mechanism and local avascularity, and post-surgical complications such as repair failure are not uncommon. One proposed predictor of outcomes following flexor tendon repair has been timing of surgery from initial injury. However, the effect of the timing of flexor tendon repair on failure rates remains controversial and understudied. The purpose of this study was to compare the failure rates of zone II flexor tendon repairs in patients at various time intervals from onset of injury. A retrospective chart review was conducted using data from hand surgery specialists at our level 1 trauma center from January 1, 2010, through May 31, 2020. This retrospective review included 407 zone II flexor tendon repairs. The primary outcome was failure of repair. Among 407 flexor tendon repairs, there were 12 reported repair failures. The failure rate was 2.9%. In the non-failure group, the mean number of days between the date of injury and the date of surgery was 7±13 days. For the failure group, this value was 14±17 days. Repairs occurring within 14 days had a failure rate of 2.3%, while repairs occurring beyond 14 days had a failure rate of 7.7%. This study demonstrates that there is a benefit to repairing the tendon within a 14-day window, as evidenced by a lower failure rate. More research is required to determine if other complications and overall health of the hand are also improved when a repair is performed in a more expedient manner. [Orthopedics. 2024;47(2):113-117.].

Criteria-based return to sport testing after open Latarjet reveals residual deficits and can be utilized for sports clearance with excellent outcomes at mean 3.6 year follow-up: A small case series of competitive athletes.

OBJECTIVE: The purpose of this study was to assess the use of a criteria-based return to sport (CBRTS) test to evaluate readiness for return to play (RTP) in competitive athletes that underwent open Latarjet. DESIGN: Retrospective case series. METHODS: Ten competitive athletes (mean age 19.9 years) treated with open Latarjet for recurrent glenohumeral instability underwent CBRTS testing at a mean of 5.3 months postoperatively. Testing consisted of four components: 1. isometric strength, 2. isokinetic strength, 3. endurance, and 4. function. Patients failing 0 or 1 component of the test were cleared to RTP. Patients failing multiple components underwent additional deficit-based rehabilitation. RESULTS: Of the 10 patients that tested, 4 passed their overall CBRTS test and were cleared to RTP. The remaining 6 patients failed the overall CBRTS test. Seven patients (70%) failed at least one section of the strength testing, two patients (20%) failed endurance testing, and two patients (20%) failed functional testing. At final follow-up (mean 3.6 years), 1 patient had recurrent instability (10%) and 9 patients returned to play (90%). CONCLUSIONS: CBRTS testing may be clinically useful for return to play clearance decisions after open Latarjet procedure, as it can reveal deficits that may not be identified with time-based clearance alone.

Total Shoulder Arthroplasty is associated With Less Pain and Better Functional Outcomes, but Humeral Head Resurfacing may be Preferred in Younger, Higher Demand Patients: A Short-Term Outcomes Study in Patients with Glenohumeral Osteoarthritis.

Objectives: This study aimed to compare short-term outcomes following Total Shoulder Arthroplasty (TSA) and Humeral Head Resurfacing (HHR) in patients with glenohumeral osteoarthritis (GHOA). Methods: A retrospective analysis included patients who had undergone either TSA or HHR for GHOA at a single institution. Baseline demographics, complications, range of motion (active forward flexion, FF and active external rotation, ER), visual analog scores (VAS), and Subjective Shoulder Values (SSV) were collected. Results: A total of 69 TSA and 56 HHR patients were analyzed. More HHR patients were laborers (44% versus 21%, P=0.01). There were more smokers in the TSA group (25% versus 11%, P=0.04) and more cardiovascular disease in the HHR cohort (64% versus. 6%, p<0.0001). Postoperative FF was similar, but ER was greater in the HHR (47° ± 15°) vs. TSA group (40° ± 12°, P = 0.01). VAS was lower after TSA vs. HHR (median 0, IQR 1 versus median 3.7, IQR 6.9, p<0.0001), and SSV was higher after TSA (89% ± 13% vs. 75% ± 20% after HHR; p<0.0001). Post-operative impingement was more common after HHR (32% vs. 3% for TSA, p<0.0001). All other complications were equivalent. Conclusion: While younger patients and heavy laborers had improved ER following HHR, their pain relief was greater after TSA. Decisions on surgical technique should be based on patient-specific demographic and anatomic factors.