Subacromial balloon spacer massive rotator cuff tear treatment systematic review and meta-analysis: Patient selection and physical therapy may be keys to outcome success.

PURPOSE: Subacromial balloon spacer implantation (SBSI) efficacy for massive rotator cuff tear treatment was evaluated based on perceived shoulder function, active shoulder mobility, pain, complications and research study methodological quality. The purpose was to better discern the efficacy of this device from both surgical and rehabilitative perspectives to improve patient outcomes. METHODS: PubMed, EMBASE and Cochrane Library databases were searched (1 January 2010 to 1 June 2024) using 'balloon spacer', 'subacromial spacer', 'subacromial balloon spacer', 'shoulder spacer' and 'inspace' terms. Pre-surgery (baseline), 12-month (12-m) and 24-month (24-m) post-SBSI mean changes were compared using one-way ANOVA and Scheffe post hoc tests, and comparative study effect sizes were calculated (p ≤ 0.05). RESULTS: This review consists of 27 studies with 894 patients (67.8 ± 5 years of age) and 29.4 ± 17-month follow-up. Modified Coleman Methodology Scores (MCMS) revealed fair overall quality (mean = 61.4 ± 11). Constant-Murley scores improved from 34.8 ± 6 (baseline), to 64.2 ± 9 (12-m) and 67.9 ± 8 (24-m) (12-m, 24-m > baseline, p < 0.001). ASES scores improved from 35.1 ± 14 (baseline), to 83.3 ± 7 (12-m) and 81.8 ± 5 (24-m)(12-m, 24-m > baseline, p < 0.001). VAS pain scores improved from 6.6 ± 1 (baseline), to 2.6 ± 1 (12-m) and 2.0 ± 1 (24-m) (12-m, 24-m < baseline, p < 0.001). Flexion increased from 108.5 ± 25° (baseline), to 128.5 ± 30° (12-m) and 151.2 ± 14° (24-m) (24-m > 12-m, baseline, p = 0.01). Abduction increased from 97.7 ± 24° (baseline) to 116.3 ± 23° (12-m) and 142.3 ± 15° (24-m) (24-m > 12-m, baseline, p = 0.02). External rotation (ER) in adduction changed from 33.1 ± 7° (baseline) to 32.5 ± 4° (12-m) and 53.9 ± 9° (24-m)(24-m > 12-m, baseline, p = 0.01). ER at 90° abduction increased from 56.3 ± 3° (baseline) to 83.5 ± 5° (12-m) and 77.1 ± 4° (24-m) (24-m, 12-m > baseline, p = 0.01). Comparison studies, however, displayed insignificant results with small effect sizes. CONCLUSION: Despite overall fair MCMS scores, at 24-m post-SBSI, shoulder function improved and pain decreased. More rigorous comparative studies, however, revealed insignificant findings. Patients with the potential to re-establish the essential glenohumeral joint force couple that depresses the humeral head on the glenoid fossa and who comply with physical therapy may be more likely to achieve success following SBSI. LEVEL OF EVIDENCE: Level IV.

Adolescent Athletes with Stronger Athletic Identity Perceptions Have Weaker Fear Avoidance Perceptions During Musculoskeletal Injury Rehabilitation Return to Sports Preparation.

BACKGROUND: Adolescent athletes who sustain a musculoskeletal sports injury are at high re-injury risk. This prospective study evaluated athletic identity perception and fear avoidance perception relationships during the return to sport preparation phase of musculoskeletal injury rehabilitation. METHODS: From 140 consecutive physical therapy outpatients, 50 (26 females, 24 males) adolescent athletes (mean age 16.8, range 14 to 22 y) completed the 7-item Athletic Identity Measurement Scale (AIMS), the 10-item Athletic Fear Avoidance Questionnaire (AFAQ), and the AFAQ with 2 additional movement-related fear and pain questions (AFAQ+). Correlational analysis was performed of overall AIMS and AIMS subscale scores (social identity, exclusivity, negative affectivity), with AFAQ and AFAQ+ scores (P≤0.05). RESULTS: Adolescent athletes were receiving treatment for musculoskeletal injuries sustained during soccer (n=10), lacrosse (n=7), baseball (n=6), basketball (n=5), volleyball (n=5), track or cross country (n=4), American football (n=4), field hockey or ice hockey (n=3), softball (n=2), tennis (n=2), and gymnastics (n=2). Lower extremity conditions included anterior cruciate ligament reconstruction (n=23) or other lower extremity conditions (n=17). Upper extremity conditions included shoulder dislocation or labral repair (n=6), elbow sprain or fracture (n=3), and clavicle fracture (n=1). The AIMS score displayed moderate inverse relationships with AFAQ (r=-0.40, P=0.008) and AFAQ+ (r=-0.41, P<0.004) scores. The "social identity" AIMS subscale score displayed a moderate inverse relationship with AFAQ (r=- 0.48, P<0.001) and AFAQ+ (r=-0.46, P=0.001) scores. The "exclusivity" AIMS subscale score displayed moderate inverse relationships with AFAQ (r=-0.40, P=0.005) and AFAQ+ (r=-0.46, P=0.001) scores. The "negative affectivity" subscale did not display significant relationships with AFAQ or AFAQ+ scores. Subject age displayed moderate inverse relationships with the AIMS "social identity" (r=-0.56, P<0.001) and "exclusivity" (r=-0.42, P=0.004) subscale scores and weak direct relationships with AFAQ (r=0.30, P=0.04) and AFAQ+ (r=0.32, P=0.02) scores. CONCLUSION: Adolescent athletes with stronger athletic identity perceptions during the return to the sports preparation phase of musculoskeletal injury rehabilitation had weaker fear avoidance perceptions. As age increased from early to late adolescence, athletic identity perceptions became weaker, and fear avoidance perceptions became stronger. To decrease re-injury rates, early identification and surveillance of injured adolescent athletes with stronger, more exclusive athletic identity perceptions and weaker fear avoidance perceptions may influence rehabilitation progression and return to play decisions. LEVEL OF EVIDENCE: Level-II, prospective cohort, correlational study.

Regenerative Anterior Cruciate Ligament Healing in Youth and Adolescent Athletes: The Emerging Age of Recovery Science.

Anterior cruciate ligament (ACL) injuries mainly arise from non-contact mechanisms during sport performance, with most injuries occurring among youth or adolescent-age athletes, particularly females. The growing popularity of elite-level sport training has increased the total volume, intensity and frequency of exercise and competition loading to levels that may exceed natural healing capacity. Growing evidence suggests that the prevailing mechanism that leads to non-contact ACL injury from sudden mechanical fatigue failure may be accumulated microtrauma. Given the consequences of primary ACL injury on the future health and quality of life of youth and adolescent athletes, the objective of this review is to identify key "recovery science" factors that can help prevent these injuries. Recovery science is any aspect of sports training (type, volume, intensity, frequency), nutrition, and sleep/rest or other therapeutic modalities that may prevent the accumulated microtrauma that precedes non-contact ACL injury from sudden mechanical fatigue failure. This review discusses ACL injury epidemiology, current surgical efficacy, the native ACL vascular network, regional ACL histological complexities such as the entheses and crimp patterns, extracellular matrix remodeling, the concept of causal histogenesis, exercise dosage and ligament metabolism, central nervous system reorganization post-ACL rupture, homeostasis regulation, nutrition, sleep and the autonomic nervous system. Based on this information, now may be a good time to re-think primary ACL injury prevention strategies with greater use of modified sport training, improved active recovery that includes well-planned nutrition, and healthy sleep patterns. The scientific rationale behind the efficacy of regenerative orthobiologics and concomitant therapies for primary ACL injury prevention in youth and adolescent athletes are also discussed.

A two-year comparison of reverse total shoulder arthroplasty mini-humeral tray and augmented mini-glenoid baseplate implants vs. standard implants.

BACKGROUND: Patients who undergo reverse total shoulder arthroplasty (RTSA) are getting younger with greater function expectations. This retrospective, longitudinal study of prospectively collected data compared perceived shoulder function and strength, active shoulder mobility, radiographic evidence of scapular notching, and implant survival over the initial 2-years post-RTSA among patient groups who received either standard central fixation point liner and glenoid baseplate implants, or lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants. MATERIALS AND METHODS: Patients who underwent primary RTSA using standard central fixation point liner and glenoid baseplate implants (Group 1, n = 180) were compared with patients who underwent primary RTSA using lower size profile mini-humeral tray with offset trunnion options and mini-augmented glenoid baseplate implants (Group 2, n = 53) for active shoulder mobility, American Shoulder and Elbow Surgeons (ASES) score, perceived ability to lift 10 lbs (4.5 kg) overhead, radiographic evidence of scapular notching, and implant survival. Data was collected pre-surgery, 6-weeks, 6-months, 1-year, and 2-years post-RTSA (p ≤ 0.05). RESULTS: More Group 2 patients had more complex B or C Walch glenoid morphology, while Group 1 had more A1 or A2 types (p ≤ 0.001). Group 2 had greater active shoulder flexion at 6-months, 1-year, and 2-years (p ≤ 0.018) and external rotation (in adduction) at 6-months and 2-years (p ≤ 0.004) compared to Group 1, with higher ASES scores at 6-months and 2-years (p ≤ 0.026) (with small-to-medium effect sizes), and with more patients meeting or exceeding the minimal clinically important difference (MCID) at 2-years (p = 0.045) and patient acceptable symptomatic state (PASS) levels at 6-months, 1-year and 2-years (p ≤ 0.045). Scapular notching was identified in six of 53 (11.3%) Group 2 patients and in 32 of 180 (17.7%) Group 1 patients. Group 1 patients had more grade 2 or greater scapular notching grades compared to Group 2 (p = 0.04). Implant survival was comparable with Group 1 = eight of 180 (4.4%) and Group 2 = 1 of 53 (1.9%) of patients requiring removal for 95.6% and 98.1% implant survival, respectively. CONCLUSION: Limited scapular notching and excellent implant survival was observed in both groups. Despite including individuals with more complex glenoid deficiency, patients receiving the lower size profile implants generally displayed better active shoulder mobility and perceived shoulder function compared to those who received standard implants. These patients also more frequently met or exceeded the MCID by 2-years post-RTSA and PASS levels by 6-months, 1-year, and 2-years post-RTSA, with lower scapular notching grades. LEVEL OF EVIDENCE: Retrospective comparative study.

Mini-augmented glenoid baseplate and mini-humeral tray reverse total shoulder arthroplasty implant comparisons: two-year clinical outcomes.

BACKGROUND: Augmented glenoid baseplate and offset humeral tray reverse total shoulder arthroplasty (RTSA) implants may decrease the mechanical impingement that creates scapular notching and improve shoulder function. This study evaluated the clinical efficacy of three different RTSA glenoid baseplate and offset humeral tray combinations for patient-reported shoulder function, pain and instability, radiographic imaging evidence of glenoid baseplate or humeral stem subsidence and migration, bony changes associated with implant loosening, and scapular notching over the initial 2 years post-RTSA. Primary outcomes included active shoulder mobility, perceived function, pain, instability, scapular notching, and implant survival. METHODS: Sixty-seven patients from 6 research sites received one of three different glenoid baseplate and humeral tray combinations. Group 1 (n = 21) received a mini-augmented glenoid baseplate with a standard humeral tray; Group 2 (n = 23) received a standard glenoid baseplate and a mini-humeral tray with 3 trunnion offset options; Group 3 (n = 23) received both a mini-augmented glenoid baseplate and a mini-humeral tray with 3 trunnion offset options. Subjects underwent radiologic evaluation, completed the ASES scale, the EQ-5D-5L quality of life scale, VAS shoulder pain and instability questions, and active shoulder mobility measurements pre-operatively, and 6-weeks, 6-months, 1-2 years post-RTSA. RESULTS: Improved active shoulder mobility, quality of life, perceived function, decreased shoulder pain and instability, excellent implant survival and minimal scapular notching were observed for all groups. Group 3 had better overall active shoulder mobility than the other groups and better perceived function than Group 1. CONCLUSION: The group that received the mini-augmented glenoid baseplate and mini-humeral tray combination had better overall active shoulder flexion, external rotation at 90° abduction, and internal rotation. This group also had better perceived shoulder function compared to the group that received a mini-augmented glenoid baseplate with a standard humeral tray.

Stress shielding following stemless anatomic total shoulder arthroplasty.

Background: Finite element analysis has suggested that stemless implants may theoretically decrease stress shielding. The purpose of this study was to assess the radiographic proximal humeral bone adaptations seen following stemless anatomic total shoulder arthroplasty. Methods: A retrospective review of 152 prospectively followed stemless total shoulder arthroplasty utilizing a single implant design was performed. Anteroposterior and lateral radiographs were reviewed at standard time points. Stress shielding was graded as mild, moderate, and severe. The effect of stress shielding on clinical and functional outcomes was assessed. Also, the influence of subscapularis management on the occurrence of stress shielding was determined. Results: At 2 years postoperatively, stress shielding was noted in 61 (41%) shoulders. A total of 11 (7%) shoulders demonstrated severe stress shielding with 6 occurring along the medial calcar. There was one instance of greater tuberosity resorption. At the final follow-up, no humeral implants were radiographically loose or migrated. There was no statistically significant difference in clinical and functional outcomes between shoulders with and without stress shielding. Patients undergoing a lesser tuberosity osteotomy had lower rates of stress shielding, which was statistically significant (p = 0.021). Discussion: Stress shielding does occur at higher rates than anticipated following stemless total shoulder arthroplasty, but was not associated with implant migration or failure at 2 years follow-up. Level of evidence: IV, Case series.

Interpositional scaffold anchor rotator cuff footprint tear repair: excellent survival, healing, and early outcomes.

PURPOSE: Shoulder function limitation duration after a full-thickness rotator cuff tendon (RCT) tear may influence post-repair healing and outcomes. A suture anchor was developed to improve footprint repair fixation and healing through biological fluid delivery and scaffold augmentation. The primary multicenter study objective was to evaluate RCT repair failure rate based on 6-month MRI examination, and device survival at 1-year follow-up. The secondary objective was to compare the clinical outcomes of subjects with shorter- and longer-term shoulder function limitation duration. METHODS: Seventy-one subjects (46 men) with moderate-to-large RCT tears (1.5-4 cm), at a median 61 years of age (range = 40-76), participated in this study. Pre-repair RCT tear location/size and 6-month healing status were confirmed by an independent radiologist. Subjects with shorter- (Group 1: 17.8 ± 21 days, n = 37) and longer-term (Group 2: 185.4 ± 89 days, n = 34) shoulder function limitation durations were also compared over 1 year for active mobility, strength, American Shoulder and Elbow Surgeon's Shoulder Score (ASES score), Veterans RAND 12 Item Health Survey (VR-12), and visual analog scale (VAS) pain and instability scores. RESULTS: Three of the 52 subjects [5.8%] who underwent 6-month MRI experienced a re-tear at the original RCT footprint repair site. By the 1-year follow-up, overall anchor survival was 97%. Although Group 2 displayed lower ASES and VR-12 scores pre-repair (ASES = 40.1 ± 17 vs. 47.9 ± 17; VR-12 physical health (PH) = 37.2 ± 9 vs. 41.4 ± 8) (p ≤ 0.048), at 3-month post-RCT repair (ASES = 61.3 ± 19 vs. 71.3 ± 20; VR-12 PH = 40.8 ± 8 vs. 46.8 ± 9) (p ≤ 0.038), and at 6-month post-RCT repair (ASES = 77.4 ± 18 vs. 87.8 ± 13; VR-12 PH = 48.9 ± 11 vs. 54.0 ± 9) (p ≤ 0.045), by 1-year post-RCT repair, groups did not differ (n.s.). Between-groups VR-12 mental health score differences were not evident at any time period (n.s.). Shoulder pain and instability VAS scores also did not differ (n.s.), displaying comparable improvement between groups from pre-RCT repair to 1-year post-RCT repair. Groups had comparable active shoulder mobility and strength recovery at each follow-up (n.s.). CONCLUSION: At 6-month post-RCT repair, only 3/52 of patients [5.8%] had a footprint re-tear, and at 1-year follow-up, overall anchor survival was 97%. Use of this scaffold anchor was associated with excellent early clinical outcomes regardless of shoulder function impairment duration. LEVEL OF EVIDENCE: II.

Liposomal bupivacaine nerve block provides better pain control post-total shoulder arthroplasty than continuous indwelling catheter.

BACKGROUND: Pain control is essential to successful total shoulder arthroplasty (TSA). MATERIALS AND METHODS: This non-blinded, randomized clinical trial compared shoulder pain, narcotic use, interscalene (IS) block application time, and costs in 76 subjects who were randomly assigned to receive either a single injection IS nerve block of 10 cc (133 mg) liposomal bupivacaine mixed with 10 cc of 0.5% bupivacaine (Group 1), or 20 cc of 0.5% ropivacaine direct injection combined with an indwelling IS nerve block catheter delivering 0.2% ropivacaine at a continual 4 cc/h infusion for the initial 3 post-operative days (Group 2). Surgical time, local anesthesia duration, hospital stay length, morphine milligram equivalents (MME) consumed, worst shoulder pain at 24, 48 and 72 h, and complications were recorded. Patient reported function, pain and activity level surveys were completed before, and 6-week post-TSA (P < 0.05). RESULTS: Group 1 had less pain 24-h (0.72 ± 0.8 vs. 3.4 ± 2.9, p < 0.0001) and 48-h (2.5 ± 2.2 vs. 4.8 ± 2.6, p = 0.005) post-TSA. At 24-h post-TSA, MME consumption was similar (Group 1 = 4.5 ± 6.4 vs. Group 2 = 3.7 ± 3.8, p = 0.54), but was lower for Group 1 at 48 h (0.0 ± 0.0 vs. 0.64 ± 0.99, p = 0.001). Group 2 had longer IS block application time (10.00 ± 4.6 min vs. 4.84 ± 2.7 min, p < 0.0001). Only group 2 had a strong relationship between MME consumption over the first 24-h post-TSA and pain 24-h post-TSA (r = 0.76, p < 0.0001), a moderate relationship with pain 48-h post-TSA (r = 0.59, P = 0.001), and a weak relationship with pain 72-h post-TSA (r = 0.44, P = 0.02). Significant relationships for these variables were not observed for Group 1 (r ≤ 0.30, p ≥ 0.23). Group 1 IS block costs were less/patient than Group 2 ($190.17 vs. $357.12 USD). CONCLUSION: A single shot, liposomal bupivacaine interscalene nerve block provided better post-TSA pain control with less narcotic consumption, less time for administration and less healthcare system cost compared to interscalene nerve block using a continuous indwelling catheter. LEVEL OF EVIDENCE: Level I, Prospective, Randomized.

Reverse total shoulder arthroplasty pain and function: new perspectives from a 10-year multicenter study at the 7-year follow-up.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) can decrease shoulder pain and improve function. However, results reportedly deteriorate as patients approach mid-term follow-up and little is known about how this impacts physical health-related quality of life (PHRQOL) and mental health-related quality of life (MHRQOL). The study hypothesis was that shoulder function, pain, and medication use for pain would influence PHRQOL and MHRQOL. METHODS: This prospective cohort study involving subjects from 6 orthopedic clinics and 12 fellowship-trained surgeons evaluated the influence of RTSA on PHRQOL, MHRQOL, shoulder function, pain, instability, and medication use over the initial 7 years of a 10-year study, and device survivorship and revision rates. Clinical examination, the American Shoulder and Elbow Surgeons (ASES) score, Short Form (SF)-12 PHRQOL and MHRQOL assessments, the single assessment numeric shoulder function evaluation (SANE), visual analog scale (VAS) shoulder pain and instability scores, shoulder pain, medication use for pain, surgery satisfaction, survivorship and revision rate data were collected pre-RTSA, and at 6-week, 6-month, 1-year, 2-year, 3-year, 5-year, and 7-year follow-ups. RESULTS: Two hundred participants (108 female) of 69 ± 8.3 years of age, with gross rotator cuff deficiency (poor tissue quality or impaired dynamic stability) (n = 92), glenohumeral joint osteoarthritis (n = 88), failed primary total shoulder arthroplasty (n = 8), non-united humeral head fracture (n = 6) or 3-4 section comminuted humeral head fracture (n = 6) underwent pre-RTSA evaluation. Device survivorship was 94%. Friedman two-way ANOVA and Wilcoxon test pairwise comparisons revealed that compared to pre-RTSA, median active shoulder flexion (+ 25°) and external rotation (+ 10°) mobility improved by 6 months (p < 0.0001) and remained improved. Shoulder flexion (+ 1 grade), abduction, external rotation (+ 0.5 grade), and internal rotation strength (+ 1 grade) also improved by 6 months (p < 0.0001) and remained improved. ASES (+ 26.8), SANE (+ 17.5) and VAS pain (- 5.7) scores improved by 6 weeks (p < 0.0001) and remained improved, as medication use for shoulder pain decreased (- 24.6%) (p < 0.0001). SF-12 PHRQOL scores improved by 6 months (+ 11.5) and remained improved (p < 0.0001). Significant Spearman Rho correlations were observed between shoulder function (ASES or SANE) and SF-12 PHRQOL (r ≥ 0.52) and MHRQOL (r ≥ 0.20) scores (p < 0.0001) supporting the relationship between shoulder function and quality of life. Trend analysis revealed changing shoulder function, pain, and PHRQOL relationships between 2 and 3 years, and 5 and 7 years post-RTSA (Chi-Square, p < 0.05). CONCLUSION: Excellent device survival and good-to-excellent perceived shoulder function, and PHRQOL improvements were observed. Secondary objectives of improved shoulder mobility, strength, pain and instability were also achieved. In contrast to previous reports, subjects did not display shoulder mobility or perceived function deterioration by the 7-year follow-up. Following chronic pain relief at 6 weeks post-RTSA, subjects appear to balance PHRQOL and shoulder pain relationships at the 6-month and 1-year post-RTSA follow-ups. Careful evaluation at this time may help patients with higher pain levels and lower function expectations reverse these trends, or patients with lower pain levels and higher function expectations to optimize RTSA use and longevity.

History of Ulnar Collateral Ligament Injury and College Pitcher Fastball Profiles: A Retrospective, Observational, Live Pitching Analysis.

PURPOSE: The aim of this study was to retrospectively compare the fastball profiles of pitchers who had previously sustained grade I or II ulnar collateral ligament (UCL) injuries, were rehabilitated, and released back for competition with those of pitchers with no history of elbow injury. METHODS: Eighteen pitchers from the pitching staff of 1 National Collegiate Athletic Association Division III team participated in this study. Group 1 had a history of grade I or II UCL injury (n = 8), and group 2 (n = 10) did not. A computerized pitch tracking device was used to analyze ball movement and pitching mechanics. The hypothesis was that the pitchers with a history of injury (group 1) would display differing fastball velocity-ball movement relationships compared to those without (group 2). RESULTS: The groups had similar heights, weights, pitching experiences, and arm slot positions at ball release. The pitching coach-determined preinjury arm slot position and the postinjury computerized pitch tracking device measurements after return to competition displayed strong agreement (r = 0.83), suggesting comparable pre and postinjury pitching techniques. The groups had comparable glenohumeral joint range of motion and fastball profiles, except that group 1 released the ball at a 2.5 times lesser horizontal distance away from the pitching rubber center. Group 2 also displayed consistently more robust and more frequent fastball movement relationships with velocity, horizontal break, and vertical break than group 1. CONCLUSIONS: Reduced horizontal ball release distances at comparable vertical ball release heights without changes in the arm slot position suggest that pitchers with a history of grade I or II UCL injury have greater contralateral trunk tilt and elbow flexion at ball release. Increased contralateral trunk tilt may occur to increase pitch velocity at the expense of ball movement while placing the pitching elbow in a potentially injurious position. Computerized fastball profile analysis using a computerized pitch tracking device, in conjunction with coach pitching technique observation, and team medical staff clinical examination may help better identify pitchers with an increased risk of UCL injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Editorial Commentary: Time-Zero Biomechanical Shoulder Instability Studies Are Valuable But Limited Because They Do Not Replicate Clinical Dynamics.

Severe anterior shoulder instability with glenoid bone loss can be very difficult to treat. A recent cadaveric, biomechanical, time-zero study compared the stability of Bankart repair with long head of the biceps brachi transfer versus conjoined tendon transfer in the scenario of 20% anteroinferior glenoid bone loss. The result is long head of the biceps tendon transfer in combination with the Bankart repair provided the best overall condition compared to Bankart repair alone, or with a conjoined tendon transfer. However, a limitation is that this does not confirm that this surgical approach would provide sufficient long-term noncontractile shoulder stability to withstand repetitive soft-tissue loading in a dynamic, clinical situation.

Sex-related differences in stemless total shoulder arthroplasty.

BACKGROUND: The use of stemless humeral implants for shoulder arthroplasty is becoming increasingly widespread. However, little is known about the difference in clinical, functional, and radiographic outcomes of stemless shoulder arthroplasty between men and women. Men and women do have reported differences in size, strength, and bone quality. As such, the purpose of this study was to evaluate sex-related differences in outcomes when using stemless humeral implants. METHODS: A retrospective review of 227 patients (men = 143 and women = 84) undergoing stemless shoulder arthroplasty was compared for sex-related differences. Clinical, functional, and radiographic outcomes were compared, including American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, range of motion, radiolucencies, operative data, implant data, and complications. Statistical analysis included descriptive statistics, t-tests, chi-square tests, and logistic regression. RESULTS: Preoperatively, men had a statistically significant greater range of motion of forward elevation (P < .01), external rotation (ER) at adduction (P = .04), ER at 90° abduction (P = .03), and baseline ASES scores (P < .01). At 2 years, there were no differences between men and women in ASES score (P = .12), visual analog scale pain score (P = .74), active ER (P = .98), implant migration, or radiolucencies (P > .99). Mean operating time was 9 minutes longer in male patients (P < .01). There was no significant difference in surgical complications, including dislocation, fracture, infection, or loosening. The three-year revision-free survival was 98.8% for women and 97.9% for men. CONCLUSION: Patient sex is not predictive of postoperative functional outcomes after stemless shoulder arthroplasty. The operative time was significantly shorter in female patients, and there was no significant difference in surgical complications between men and women.

Trunk and lower extremity long-axis rotation exercise improves forward single leg jump landing neuromuscular control.

BACKGROUND: Anterior cruciate ligament (ACL) injuries often involve sudden single leg loading with directional changes. Trunk and lower extremity (LE) load transfer and muscle power are directly coupled during these movements. The effect of trunk and LE long-axis rotation training on forward single leg drop jump landing and stabilization (FSLDJLS) was studied. METHODS: Using block randomization (gender), 36 (18 men, 18 women) subjects were assigned to experimental (nine, 20 min exercise sessions) and control groups with equal subject number. Ground reaction force (1000 Hz), kinematic (60 Hz) and LE EMG (1000 Hz) data were synchronously collected. Statistical analysis compared pre- and post-test neuromuscular control mean change differences (MCD), and hip flexion-LE peak EMG % maximum volitional isometric contraction (%MVIC) (expressed as decimal equivalents), mean change difference (MCD) relationships. RESULTS: The experimental group had greater landing knee flexion (3.5 ± 3.6° vs. -0.4 ± 3.3°, p = .002) MCD, greater dynamic LE stiffness after landing (0.09 ± 0.14 vs. -0.11 ± 0.14, p = .001) MCD, and increased gluteus maximus (GMAX) (0.20 ± 0.39%MVIC vs. -0.23 ± 0.46%MVIC, p = .006) and gluteus medius (GMED) EMG amplitude (0.22 ± 0.31 vs. -0.07 ± 0.36%MVIC, p = .018) MCD. This group also had decreased GMAX (-166.5 ± 403.6 ms vs. 89.3 ± 196 ms, p = .025), GMED (-75.9 ± 126.8 ms vs. 131.2 ± 207.1 ms, p = .002) and vastus lateralis (-109.1 ± 365 ms vs. 205.5 vs. 510 ms, p = .04) activation duration MCD. More experimental group subjects had increased landing knee flexion MCD (15/18 vs. 8/18, p = .015), increased dynamic LE stiffness MCD (15/18 vs. 2/18, p < .0001) and increased GMAX (15/18 vs. 7/18, p = .006) and GMED (17/18 vs. 10/18, p = .007) EMG amplitude MCD, and reduced GMAX (12/18 vs. 6/18, p = .046), GMED (11/18 vs. 5/18, p = .044), rectus femoris (12/18 vs. 6/18, p = .046), and vastus lateralis (13/18 vs. 7/18, p = .044) EMG activation duration MCD. Only the experimental group displayed significant relationships between landing and peak hip flexion and peak LE EMG amplitude MCD. CONCLUSION: Increased dynamic LE stiffness, increased hip muscle EMG amplitude and decreased hip and knee muscle activation duration MCD in the experimental group suggests improved LE neuromuscular control.

Treatment of Partial-Thickness Rotator Cuff Tears With a Resorbable Bioinductive Bovine Collagen Implant: 1-Year Results From a Prospective Multicenter Registry.

BACKGROUND: Surgical treatment of partial-thickness rotator cuff tears remains challenging and controversial, with several traditional options including debridement with acromioplasty, transtendon or in situ repair, and take-down and repair. A resorbable bioinductive bovine collagen implant has shown promise as an alternative treatment option for partial-thickness tears. PURPOSE: Data from a registry were analyzed to further establish that the implant contributes to improved patient-reported outcome (PRO) scores across a large number of patients treated for partial-thickness rotator cuff tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 19 centers in the United States enrolled patients >21 years old with partial-thickness tears of the rotator cuff in a comprehensive prospective multicenter registry. PRO scores were recorded preoperatively and postoperatively at 2 and 6 weeks, 3 and 6 months, and 1 year: American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey (physical and mental component scores), and Western Ontario Rotator Cuff scores. Revisions were reported throughout the study. RESULTS: The registry included 272 patients with partial-thickness tears (49 grade 1 tears, 101 grade 2 tears, and 122 grade 3 tears), 241 who underwent isolated bioinductive repair (IBR; collagen implant placed after bursectomy without a traditional rotator cuff repair), and 31 who had take-down and repair with bioinductive augmentation. Patients experienced statistically significant and sustained improvement from baseline for all PRO scores beginning at 3 months. Among patients with grade ≥2 tears, those with take-down and repair had significantly inferior scores at 2 and 6 weeks for most PRO scores as compared with those who underwent IBR, but the difference was no longer significant at 1 year for all but the physical component score of the Veterans RAND 12-Item Health Survey. There were 11 revisions, which occurred at a mean ± SD of 188.7 ± 88.0 days after the index surgery. There were no infections. CONCLUSION: This registry analysis further establishes across a large data set that this resorbable bioinductive bovine collagen implant improves PROs in all grades of partial-thickness tears, whether used as IBR or in conjunction with take-down and repair. IBR may offer improved early clinical outcomes (≤6 weeks) and comparable outcomes at 1 year when compared with a more invasive "take-down and repair" approach.

A multicenter, prospective 2-year analysis of the Sidus stem-free shoulder arthroplasty system.

BACKGROUND: The purpose of this multicenter, prospective study was to evaluate the efficacy and safety of a stemless total shoulder arthroplasty compared with a traditional stemmed control. METHODS: Ninety-five shoulders were selected for participation in this Food and Drug Administration investigational device exemption clinical trial and underwent stemless total shoulder arthroplasty. Subjects returned for follow-up at 6 weeks, 6 months, 12 months, and 2 years postoperatively. Outcome measures included pain; range of motion; American Shoulder and Elbow Surgeons, Western Ontario Osteoarthritis of the Shoulder, and Short Form 12 scores; and radiographic review. Baseline data were compared with 2-year follow-up data to determine the rate of composite clinical success compared with the stemmed control. RESULTS: All outcome assessments demonstrated significant improvements (P ≤ .007). The mean American Shoulder and Elbow Surgeons score improved from 20 to 89 (P < .0001), and the mean shoulder pain score decreased from 8.3 ± 1.6 to 0.7 ± 1.5 (P < .0001). The mean Western Ontario Osteoarthritis of the Shoulder score decreased from 1443 ± 256 to 203 ± 267 (P < .0001). On the Short Form 12, the mean physical health score increased from 33 ± 7 to 48 ± 9 (P < .0001) and the mean mental health score increased from 50 ± 13 to 54 ± 8 (P = .007). Mean active forward elevation increased from 97° ± 27° to 143° ± 25° (P < .0001), and mean active external rotation increased from 21° ± 16° to 53° ± 18° (P < .0001). Kaplan-Meier analysis showed an implant survivorship rate of 98% at 2 years. The composite clinical success rate was 87% compared with 85% for the stemmed control. CONCLUSIONS: This study showed that a stemless rough-blasted humeral implant with metaphyseal bone fixation provides good clinical and radiographic outcomes and survivorship at 2 years, with outcomes comparable to a traditional stemmed implant.

Clinical measurements versus patient-reported outcomes: analysis of the American Shoulder and Elbow Surgeons physician assessment in patients undergoing reverse total shoulder arthroplasty.

BACKGROUND: The American Shoulder and Elbow Surgeons (ASES) score is composed of a patient-reported portion and a physician assessment. Although the patient-reported score is frequently used to assess postoperative outcomes after shoulder arthroplasty, no previous studies have used the physician-assessment component. This study evaluated the relationship of the ASES physician-assessment measurements with patient-reported shoulder and general health outcomes. METHODS: A retrospective review of a prospectively collected multicenter database was used to analyze patients who underwent primary reverse total shoulder arthroplasty (RTSA) from 2012 to 2015 with a minimum 2-year follow-up. ASES physician-assessment and patient-reported components and 12-Item Short Form Health Survey (SF-12) general health questionnaires were obtained preoperatively and 2 years postoperatively. The relationship between ASES physician measurements with ASES patient-reported outcome (PRO) scores and SF-12 Physical and Mental domain scores was assessed with Pearson correlation coefficients. RESULTS: Included were 74 patients (32 men; mean age, 69.2 years; body mass index, 29.4 kg/m2). Preoperative physician measurements and PRO scores were not significantly correlated. Postoperatively, only the ASES physician-measured active (R = 0.54, P < .01) and passive forward flexion (R = 0.53, P < .01) demonstrated moderate correlation with ASES patient scores. The remaining clinical measurements had no significant correlations with ASES patient or SF-12 scores. During the 2-year period, only improvements in active forward flexion correlated with improvements in ASES patient scores (R = 0.36, P < .01). CONCLUSIONS: Little correlation exists between clinical measurements from the ASES physician component and PROs, including the ASES patient-reported and SF-12 general health surveys, in RTSA patients. Improvement in active forward flexion is the only clinical measurement correlated with PRO improvement at 2 years.

Effect of Humeral Component Version on Outcomes in Reverse Shoulder Arthroplasty.

Although reverse shoulder arthroplasty provides excellent clinical results in appropriately selected patients, loss of external and internal rotation may occur. Component selection, design, and placement affect postoperative results. Recent studies considered the effect of humeral component version on functional results. The current study investigated whether humeral stem retroversion affects the outcomes of reverse shoulder arthroplasty with a retrospective review of a multisurgeon, industry-sponsored, prospectively gathered database of a single reverse shoulder arthroplasty implant. All patients had at least 2-year follow-up. Clinical outcomes, including American Shoulder and Elbow Surgeons score, visual analog scale pain score, Short Form-12 Mental and Physical Component scores, range of motion, and internal rotation function, were compared between patients with humeral retroversion of 10° or less (group A) and those with humeral retroversion of 20° or greater (group B). Radiographic outcomes were compared. The analysis included 64 patients (group A, 29 patients; group B, 35 patients). No clinical or statistically significant difference was found in American Shoulder and Elbow Surgeons scores. Both groups showed statistical and clinical improvement vs preoperative scores, with group A averaging 77.8 and group B averaging 79.2 at final follow-up. No differences were found between groups in range of motion or ability to perform tasks that require shoulder internal rotation. Patients can expect good clinical improvement after reverse shoulder arthroplasty. No difference was found in clinical or radiologic outcomes based on humeral component retroversion. Despite the theoretical increase in external rotation when the humeral component is placed closer to native retroversion, the results did not show this effect. [Orthopedics. 2017; 40(3):179-186.].

Distal biceps brachii tendon repair: a systematic review of patient outcome determination using modified Coleman methodology score criteria.

PURPOSE: This systematic literature review evaluated the methodological research design quality of studies that evaluated patient outcomes following distal biceps brachii tendon repair and developed evidence-based recommendations for future patient clinical outcomes research. METHODS: Following the preferred reporting items for systematic reviews and meta-analyses criteria, and using "biceps brachii", "tendon", "repair" and "outcome assessment" search terms, the CINAHL, Academic Search Premier and MEDLINE databases were searched from January 1960-October 2015. The modified Coleman methodology score (MCMS) served as the primary outcome measure. Descriptive statistical analysis was performed for composite and component MCMS and for patient outcome assessment methodology use frequency. RESULTS: A total of 93 studies were evaluated. Overall MCMS was low (57.1 ± 14). Only 12 (12.9 %) had prospective cohort or randomized controlled trial designs. There was a moderate relationship between publication year and MCMS (r = 0.53, P < 0.0001). Although 61 studies (65.6 %) had adequate surgical descriptions, only 3 (3.2 %) had well-described rehabilitation. Of 2253 subjects, only 39 (1.7 %) were women. Studies published after 2008 had higher MCMS scores than studies published earlier (61.3 ± 10 versus 52.9 ± 16, P = 0.003). CONCLUSION: Although overall research study methodological scores improved on average since 2008, generally low MCMS scores, retrospective designs, lack of eccentric elbow flexor or supinator strength testing, and poorly described surgical and rehabilitation descriptions remain commonplace. These findings decrease clinical study validity and generalizability. LEVEL OF EVIDENCE: III.

Reverse-total shoulder arthroplasty cost-effectiveness: A quality-adjusted life years comparison with total hip arthroplasty.

AIM: To compare reverse-total shoulder arthroplasty (RSA) cost-effectiveness with total hip arthroplasty cost-effectiveness. METHODS: This study used a stochastic model and decision-making algorithm to compare the cost-effectiveness of RSA and total hip arthroplasty. Fifteen patients underwent pre-operative, and 3, 6, and 12 mo post-operative clinical examinations and Short Form-36 Health Survey completion. Short form-36 Health Survey subscale scores were converted to EuroQual Group Five Dimension Health Outcome scores and compared with historical data from age-matched patients who had undergone total hip arthroplasty. Quality-adjusted life year (QALY) improvements based on life expectancies were calculated. RESULTS: The cost/QALY was $3900 for total hip arthroplasty and $11100 for RSA. After adjusting the model to only include shoulder-specific physical function subscale items, the RSA QALY improved to 2.8 years, and its cost/QALY decreased to $8100. CONCLUSION: Based on industry accepted standards, cost/QALY estimates supported both RSA and total hip arthroplasty cost-effectiveness. Although total hip arthroplasty remains the quality of life improvement "gold standard" among arthroplasty procedures, cost/QALY estimates identified in this study support the growing use of RSA to improve patient quality of life.