A Transitional Pain Management Program Is Associated with Reduced Opioid Dependence after Major Shoulder Surgery.

BACKGROUND: Over-prescription of opioids in the United States increases risks of opioid dependence, overdose, and death. Increased perioperative and postoperative opioid use during orthopedic shoulder surgery is a significant risk factor for long term opioid dependence. The authors hypothesized that a multidisciplinary perioperative pain management program (Transitional Pain Service or TPS) for major shoulder surgery would lead to a reduced amount of opioids required postoperatively. METHODS: A TPS was implemented at a Veterans Affairs Medical Center focused on non-opioid pain management and cessation support. Opioid consumption during the implementation of the TPS was compared to a historical cohort. All patients undergoing shoulder arthroplasty or rotator cuff repair were included. The primary outcome was the proportion of patients continuing opioid use at 90 days postoperatively. Secondary outcomes included postoperative pain scores, time to opioid cessation, and median opioid tablets consumed at 90-days. A multivariable model was developed to predict total opioid use at 90-days postoperatively. Kaplan Meier curves were calculated for time to opioid cessation. RESULTS: The TPS group demonstrated decreased persistent opioid use at 90 days post-discharge (12.6% vs. 28.6%; p=0.018). Independent predictors associated with increased total opioid tablet prescriptions at 90 days included length of stay (ß=19.17), anxiety diagnosis (ß=37.627), and number of tablets prescribed at discharge (ß=1.353). Shoulder arthroplasty surgery (TSA) was associated with decreased 90-day opioid utilization (ß= -32.535) when compared to cuff repair (RCR). Median time to cessation was shorter in TSA (6 days) when compared with RCR (8 days). Pain scores were reduced compared to population mean by post-discharge day 2 for TSA and by post-discharge day 7 for RCR. Median number of post-discharge opioid tablets (oxycodone 5 mg) consumed under TPS management was 25 in both RCR and TSA surgery groups (180 MME). DISCUSSION AND CONCLUSIONS: This study demonstrates that a TPS reduces the amount of opioid use of patients undergoing shoulder arthroplasty or cuff repair at 90 days when compared with a historical control. Multivariable regression indicated that fewer opioid tablets at discharge was a modifiable factor that may aid in reducing opioid consumption and that anxiety diagnosis, increased length of stay, and cuff repair surgery were other factors independently associated with increased opioid consumption. This data will assist surgeons in counseling patients, setting narcotic use expectations, and minimizing overprescribing. Use of a similar multidisciplinary perioperative pain management program may greatly reduce opioid over prescriptions nationally.

Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial.

BACKGROUND: The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up. METHODS: This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up. RESULTS: Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168). CONCLUSION: The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection. LEVEL OF EVIDENCE: III.

Comparison of 3D Computer Assisted Planning With and Without Patient Specific Instrumentation for Severe Bone Defects in Reverse Total Shoulder Arthroplasty.

BACKGROUND: Preoperative planning is an integral aspect of managing complex deformity in reverse shoulder arthroplasty (RSA). The purpose of this study was to compare the success of patient specific instrumentation (PSI) and 3D computer-assisted planning with standard instrumentation (Non-PSI) in achieving planned corrections of the glenoid among patients undergoing RSA with severe bony deformity requiring glenoid bone grafts. METHODS: A retrospective case-control study was performed, including all patients that underwent RSA with combined bone grafting procedures (BIO-RSA or structural bone grafting) for severe glenoid deformity by a single between June 2016 and July 2023. Patients were required to have preoperative and postoperative CT scans as well as preoperative 3D planning performed for inclusion. Patients were divided into two groups based on the use of 3D computer-assisted planning with or without PSI (PSI vs. Non-PSI). The corrected inclination and version were measured by two separate reviewers on preoperative and postoperative 2D CT scans and compared to their corresponding preoperative planning goals utilizing bivariate analyses. RESULTS: We identified 45 patients that met our inclusion criteria (22 PSI and 23 Non-PSI). Preoperative inclination (mean ± SD) (PSI 10.12° ± 15.86°, Non-PSI 9.43° ± 10.64°; P = 0.864) and version (PSI -18.78° ± 18.3°, Non-PSI -17.82° ± 11.49°; P = 0.835) measurements were similar between groups. No significant differences in the mean deviation (error) between the postoperative and planned inclination (PSI 5.49° ± 3.72; Non-PSI 6.91° ± 5.05; P = 0.437) and version (PSI 8.37° ± 5.7; Non-PSI 5.37° ± 4.43; P = 0.054) were found between groups. No difference in the rate of outliers (>10° error) was noted in inclination (P = 0.135) or version (P = 0.445) between groups. Greater planned version correction was correlated with greater error when PSI was utilized (PSI r = 0.519, P = 0.013; Non-PSI r = 0.362, P = 0.089). CONCLUSION: Both PSI and 3D computer-assisted planning without PSI (Non-PSI) appear to be useful techniques to achieve version and inclination correction among patients undergoing RSA with severe glenoid deformity required glenoid bone grafting with no clear superiority of one method over the other. Surgeons should be aware that when utilizing PSI, slightly greater error in achieving version goals may occur as version correction is increased.

The Effect of Lateralization and Distalization After Grammont-Style Reverse Total Shoulder Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the relationship between multiple radiographic measures of lateralization and distalization and clinical outcome scores after reverse total shoulder arthroplasty (RTSA). METHODS: We retrospectively evaluated all RTSAs performed by the senior author between January 1, 2007, and November 1, 2017. We then evaluated the visual analog scale for pain (VAS pain), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores and complication and reoperation rates at a minimum of 2-year follow-up. We measured preoperative and postoperative (2-week) radiographs for the lateralization shoulder angle (LSA), the distalization shoulder angle (DSA), lateral humeral offset (LHO), and distance from glenoid to lateral aspect of the greater tuberosity (GLAGT). A multivariable analysis was performed evaluating the effect of the postoperative radiographic measurements on final patient reported outcomes (ASES scores, SST, VAS pain). RESULTS: The cohort included 216 shoulders from unique patients who had patient reported outcome scores available at a minimum of 2-year follow-up (average, 4.0±1.9 years) for a total follow-up rate of 70%. In the multivariable models, more lateralization (LSA) was associated with worse final ASES scores -0.52 (95% CI: -0.88 to -0.17; p=0.004), and more distalization (DSA) was associated with better final ASES scores 0.40 (95% CI: 0.11, 0.69; p=0.007). More lateralization (LSA) was associated with worse final SST scores -0.06 (95% CI: -0.11, -0.003; p=0.039). Finally, greater distalization (DSA) was associated with lower final VAS pain scores, Ratio = 0.98 (95% CI: 0.96, 1.00; p=0.021). CONCLUSION: Greater distalization and less lateralization are associated with better function and less pain after Grammont-style RTSA. If utilizing a Grammont-style implant, remaining consistent with Grammont's principles of implant placement will afford better final clinical outcomes.

Three-month Delay in Rotator Cuff Repair: 2-year Follow-up.

INTRODUCTION: This study examined 2-year outcomes of patients who underwent delayed rotator cuff repair (RCR) compared with those who underwent RCR without delay. METHODS: In this prospective comparative study, two groups were formed: (1) patients planning RCR during a 6-week elective surgery ban and (2) patients undergoing RCR at least 6 weeks after the ban. The Simple Shoulder Test, American Shoulder and Elbow Surgeon score, and visual analog scale for pain were collected preoperatively and at 2 years postoperatively. Magnetic resonance imaging assessed healing 6 months postoperatively. RESULTS: With a 93.3% 2-year follow-up (13/15 delay group, 15/15 control), there was an 87-day difference in presentation to surgery (P = 0.001), with no significant preoperative demographic or tear characteristic differences between groups. Intraoperatively, there were no differences between groups in repair characteristics. Preoperative versus postoperative differences in American Shoulder and Elbow Surgeon score (P < 0.001), visual analog scale (P < 0.001), and Simple Shoulder Test scores (P < 0.001) were significant but not between groups (P = 0.650, 0.586, 0.525). On MRI, 58% in the delay group and 85% in the control group had healed (P = 0.202). DISCUSSION: Although a 3-month delay showed no statistically significant effect on outcomes, the delay group had an approximately 27% higher failure rate. Thus, although a 3-month period of nonsurgical treatment before RCR may be reasonable, larger studies are warranted for definitive conclusions.

Preoperative Planning Software Does Not Accurately Predict Range of Motion in Reverse Total Shoulder Arthroplasty.

BACKGROUND: The purpose of this study was to determine whether preoperative planning software (PPS) accurately predicts clinical range of motion (ROM) in patients with reverse total shoulder arthroplasty 1 year postoperatively with preoperative and postoperative computed tomography (CT) scans. METHODS: This was a retrospective study of 16 reverse total shoulder arthroplasty patients with preoperative and postoperative (CT) scans obtained at least 1 year postoperatively. Clinical ROM was measured in abduction, external rotation at resting abduction, extension, and flexion at a minimum of 1 year postoperatively. All clinical measurements were obtained before generation of PPS ROM values. Using postoperative CT scans, the achieved implant component positions were quantified and then replicated in PPS on the preoperative CT scans. The preoperative predicted ROM was then recorded, both with and without osteophyte removal. Bland-Altman plots were generated within each motion comparing the differences between clinically measured motion and software-predicted motion. RESULTS: The variation in clinically measured ROM in abduction, external rotation at resting abduction, extension, and flexion were 118 ± 27 (65° to 180°), 33 ± 16 (10° to 75°), 56 ± 8 (50° to 65°), and 137 ± 25 (80° to 160°), respectively. Clinically measured motion differed greatly from PPS-predicted ROM, with mean differences of 33 ± 29 (-32 to 93) for abduction, 44 ± 25 (-38 to 57) for external rotation, 44 ± 25 (-35 to 65) for extension, and 54 ± 50 (-51 to 147) for flexion with no significant correlations between clinically measured and PPS-predicted ROM ( P > 0.05). With humeral or humeral and glenoid osteophyte resection, correlations for only flexion became significant ( P = 0.002 for both). CONCLUSION: The passive glenohumeral impingement-free ROM generated from PPS incompletely predicts clinically measured active humerothoracic ROM, possibly because of the unmeasured factors of soft-tissue tension, muscular strength, humeral torsion, resting scapular posture, and, most importantly, scapulothoracic motion. LEVEL OF EVIDENCE: IV.

Estrogen and testosterone supplementation improves tendon healing and functional recovery after rotator cuff repair.

Failure of healing after rotator cuff repair (RCR) is common. The purpose of the current study was to evaluate the effect of systemic estrogen or testosterone supplementation on tendon healing after RCR. Seventy-two adult male mice were utilized for all experiments. The supraspinatus tendon was transected and repaired with 6-0 Prolene suture on the left shoulder of 51 animals. Mice were segregated into three groups postoperative: (1) vehicle group (VG; n = 18), (2) estrogen group (EST; n = 17), and (3) testosterone group (TST; n = 16). An unrepaired control group (unrepaired, n = 21) did not have surgery. Utilizing these animals, histological analysis, activity testing, biomechanical testing and RNA sequencing (RNA-seq) was performed. At 8 weeks post-RCR, TST, and EST supplementation improved the overall histologic structure of the repaired enthesis site. No differences in ultimate failure loads or stiffness were detected between VG, EST, and TST groups after biomechanical testing. RCR caused a reduction in wheel activity compared to unrepaired controls and supplementation with TST restored wheel activity. RNA-seq analysis indicated that estrogen and testosterone regulated different pathways associated with enthesis healing, including a suppression of inflammatory signaling. Supplementation with sex hormones improved the structure of the repaired tendon enthesis and significantly regulated expression of diverse pathways regulating multiple biological processes. Testosterone administration following RCR restored wheel activity without having a detrimental impact on biomechanical strength. Future human studies of sex hormone supplementation after RCR are warranted as supplementation in an animal model may improve tendon enthesis healing.

Biomechanical comparison of suture bridge rotator cuff repair with and without dermal allograft pledgets.

BACKGROUND: One method to augment rotator cuff repair is to pass dermal allograft pledgets along the sutures that bridge from the medial to the lateral row. It remains unclear whether this augmentation method alters repair biomechanics. METHODS: This was a controlled laboratory study. After an a priori power analysis, 9 pairs of rotator cuffs underwent double-row suture bridge rotator cuff repair, half randomized to augmentation with dermal allograft pledgets passed along the suture bridge sutures. Repairs were then mounted on a material testing system and loaded cyclically 500 cycles to measure applied force and displacement. Repairs then underwent ultimate failure testing, and stiffness, ultimate failure force, and ultimate failure displacement were measured. Paired t tests were performed to compare between groups. RESULTS: There were no differences between groups in construct gapping with cyclic loading after 500 cycles (P = .885). There were no differences between the augmented and control groups in yield force (103.5 ± 5.0 vs. 101.4 ± 5.9 N, respectively, P = .183), stiffness (94.2 ± 13.9 vs. 90.9 ± 13.8, P = .585), or ultimate failure force (255.3 ± 65.8 vs. 285.3 ± 83.2, P = .315). There were no differences between groups in failure modes, with most specimens failing by cuff tissue tearing within or medial to the construct. CONCLUSION: The addition of dermal allograft pledgets does not positively or negatively influence the time-zero biomechanical characteristics of double-row suture bridge rotator cuff repair.

Common Complication From Routine Shoulder Surgery: Postoperative Stiffness After Rotator Cuff Repair.

Rotator cuff repair is commonly performed, and stiffness represents one of the most common complications. Unique characteristics of postoperative stiffness, including its natural history and pathoanatomy, differentiate it from other etiologies of shoulder stiffness. Patient risk factors that have been associated with postoperative stiffness should be reviewed to better help clinicians tailor their presurgical risk assessment. Although stiffness in this setting has clinical consequences for patients' postoperative shoulder function, it is important to discuss the important implications of stiffness as it relates to rotator cuff healing. Multiple strategies have been proposed to decrease the incidence of postoperative stiffness. There is evidence to support these preventive strategies, and it has led to author recommendations for treatment of refractory cases and prevention.

Inlay vs. onlay humeral components in reverse total shoulder arthroplasty: a biorobotic shoulder simulator study.

BACKGROUND: Both inlay and onlay humeral implants are available for reverse total shoulder arthroplasty (rTSA), but biomechanical data comparing these components remain limited. This study investigated the effects of inlay and onlay rTSA humeral components on shoulder biomechanics using a biorobotic shoulder simulator. METHODS: Twenty fresh-frozen cadaveric shoulders were tested before and after rTSA with either an inlay or onlay humeral implant. Comparisons were performed between the most commonly implanted configurations for each implant (baseline) and with a modification to provide equivalent neck-shaft angles (NSAs) for the inlay and onlay configurations. Specimens underwent passive range-of-motion (ROM) assessment with the scapula held static, and scapular-plane abduction was performed, driven by previously collected human-subject scapulothoracic and glenohumeral kinematics. Passive ROM glenohumeral joint angles were compared using t tests, whereas muscle force and excursion data during scapular-plane elevation were evaluated with statistical parametric mapping and t tests. RESULTS: Maximum passive elevation was reduced for the inlay vs. onlay humeral components, although both implants caused reduced passive elevation vs. the native joint. Inlay rTSA also demonstrated reduced passive internal rotation at rest and increased external rotation at 90° of humerothoracic elevation vs. the native joint. All preoperative planning estimates of ROM differed from experiments. Rotator cuff forces were elevated with an onlay vs. inlay humeral implant, but simulated muscle excursions did not differ between systems. Compared with the native joint, rotator cuff forces were increased for both inlay and onlay implants and deltoid forces were reduced for inlay implants. Muscle excursions were dramatically altered by rTSA vs. the native joint. Comparisons of inlay and onlay humeral implants with equivalent NSAs were consistent with the baseline comparisons. CONCLUSIONS: Rotator cuff forces required to perform scapular-plane abduction increase following rTSA using both inlay and onlay implants. Rotator cuff forces are lower with inlay implants compared with onlay implants, although inlay implants also result in reduced passive-elevation ROM. Deltoid forces are lower with inlay implants in comparison to the native joint but not with onlay implants. The differences between inlay and onlay components are largely unaffected by NSA, indicating that these differences are inherent to the inlay and onlay designs. In those patients with an intact rotator cuff, decreased rotator cuff forces to perform abduction with an inlay humeral implant compared with an onlay implant may promote improved long-term outcomes owing to reduced deltoid muscle fatigue when using an inlay implant.

Revision Subpectoral Biceps Tenodesis Demonstrates a High Patient Satisfaction and Good Functional Outcomes.

Purpose: To clinically evaluate a subset of patients who underwent a revision subpectoral biceps tenodesis for a clinically failed proximal biceps tenodesis. Methods: This is a retrospective case series of patients with at least 2-year follow-up who had undergone a revision biceps tenodesis after clinical failure of a proximal biceps tenodesis between January 2008 and February 2020 by a single surgeon. Patients who underwent concomitant procedures, such as revision cuff repair, were excluded. Patients with a minimum of 2 years duration status postrevision subpectoral tenodesis were contacted for informed consent and outcome data, which included Simple Shoulder Test, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective reporting of arm weakness and satisfaction. Results: Fourteen patients were initially identified as meeting inclusion criteria with a minimum 2-year follow-up achieved for 11 of 14 patients (78.5% follow-up). The mean follow-up time was 8.1 years (range, 2.7-14.8 years). After the primary biceps tenodesis, a mean of 8.0 ± 9.6 months passed before the revision subpectoral biceps tenodesis was performed. The average postoperative active forward elevation and adducted external rotation were 159 ± 7° and 47 ± 17°, respectively. The mean ± standard deviation (range) follow-up American Shoulder and Elbow Surgeons score was 79 ± 23 (30-100), Simple Shoulder Test was 11 ± 2 (7-12), and visual analog scale for pain was 2.6 ± 2.8 (0-9). All 11 patients reported being satisfied with their operation and would elect to have the operation again. Conclusions: Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis. Although some persistent pain is common, revision subpectoral biceps tenodesis demonstrates a high patient satisfaction and good functional outcomes. Level of Evidence: Level IV, therapeutic case series.

Comparing outcomes of central ingrowth peg vs. noningrowth pegged glenoid components during revision to reverse total shoulder arthroplasty.

Background: One innovation to reduce glenoid loosening in total shoulder arthroplasty (TSA) is a large, central ingrowth peg. However, when bone ingrowth fails to occur, there is often increased bone loss surrounding the central peg which may increase complexity of subsequent revisions. Our goal was to compare outcomes between central ingrowth pegs and noningrowth pegged glenoid components during revision to reverse total shoulder arthroplasty. Methods: In a comparative retrospective case series, all patients who underwent TSA-to-reverse TSA revision between 2014 and 2022 were reviewed. Demographic varibles as well as clinical and radiographic outcomes were collected. Ingrowth central peg and noningrowth pegged glenoid groups were compared using t-test, Mann-Whitney U, Chi-Square, or Fisher's exact tests where indicated. Results: Overall, 49 patients were included: 27 underwent revision from noningrowth and 22 from central ingrowth components. Females more commonly had noningrowth components (74% vs. 45%, P = .04) and preoperative external rotation was higher in central ingrowth components (P = .02). Time to revision was significantly earlier in central ingrowth components (2.4 vs. 7.5 years, P = .01). Structural glenoid allografting was required more with noningrowth components (30% vs. 5%, P = .03) and time to revision in patients ultimately requiring allograft reconstruction was significantly later (9.96 vs. 3.68 years, P = .03). Conclusion: Central ingrowth pegs on glenoid components were associated with decreased need for structural allograft reconstruction during revision; however, time to revision was earlier in these components. Further research should focus on whether glenoid failure is due to glenoid component design, time to revision, or both.

Progression of symptomatic bilateral rotator cuff disease.

Background: Prior studies have demonstrated that conservatively treated rotator cuff tears and rotator cuff tendinopathy may continue to progress. It is unclear whether that rate of progression differs between sides in patients with bilateral disease. This study evaluated the likelihood of progression of rotator cuff disease as confirmed via magnetic resonance imaging (MRI) in individuals with symptomatic bilateral pathology, treated conservatively for a minimum of 1 year. Methods: We identified patients with bilateral rotator cuff disease confirmed via MRI within the Veteran's Health Administration electronic database. A retrospective chart review via the Veteran's Affairs electronic medical record was performed. Progression was determined using 2 separate MRIs with a minimum of 1 year apart. We defined progression as (1) a progression from tendinopathy to tearing, (2) an increase from partial-thickness to full-thickness tearing, or (3) an increase in tear retraction or tear width of at least 5 mm. Results: Four hundred eighty MRI studies from 120 Veteran's Affair patients with bilateral, conservatively treated rotator cuff disease were evaluated. Overall, 42% (100/240) of rotator cuff disease had progressed. No significant difference was found between progression of right vs. left rotator cuff pathology, with right shoulder pathology progressing at a rate of 39% (47/120), while left shoulder disease progressed at a rate of 44% (53/120). The likelihood of disease progression was associated with less initial tendon retraction (P value = .016) and older age (P value = .025). Conclusions: Rotator cuff tears are no more likely to progress on the right, as compared to the left side. Older age and less initial tendon retraction were found to be predictors of disease progression. These suggest that higher activity level may not associate with greater progression of rotator cuff disease. Future prospective studies evaluating progression rates between dominant vs. nondominant shoulders are warranted.

Abnormal Laboratory Values for Metabolic and Hormonal Syndromes Are Prevalent Among Patients Undergoing Rotator Cuff Repair.

Purpose: To determine the prevalence of systemic laboratory abnormalities among patients undergoing rotator cuff repair (RCR). Methods: Patients who underwent RCR at the authors' institution for 1 year between October 2021 to September 2022 were retrospectively identified. Preoperative laboratory values, including serum sex hormones, vitamin D, hemoglobin A1C, and a lipid panel, were obtained as part of our routine practice during the study period. Demographics and tear characteristics were compared in patients with laboratory data and those without. For included patients with laboratory data, mean laboratory values and percentage of patients with abnormal laboratory values were recorded. Results: During a 1-year period of time, 135 RCRs were performed, of which preoperative labs were obtained on 105. Of these, 67% were sex hormone deficient, 36% were vitamin D deficient, 45% had an abnormal hemoglobin A1C, and 64% had an abnormal lipid panel. In total 4% had "normal" labs. Conclusions: In this retrospective study, sex hormone deficiency is highly prevalent among patients undergoing RCR. Nearly all patients undergoing RCR have systemic laboratory abnormalities involving either sex hormone deficiency, vitamin D deficiency, dyslipidemia, and/or prediabetes. Level of Evidence: Level IV, prognostic case series.

Adhesive Capsulitis.

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Arthroscopic scapulothoracic bursectomy with and without superomedial angle scapuloplasty: a comparison of patient-reported outcomes.

BACKGROUND: Operative treatment of scapulothoracic bursitis most commonly comprises arthroscopic scapulothoracic bursectomy with or without partial superomedial angle scapuloplasty. There is currently no consensus regarding whether or when scapuloplasty should be performed. Prior studies are limited to small case series, and optimal surgical indications are not yet established. The purposes of this study were (1) to retrospectively review patient-reported outcomes of arthroscopic treatment of scapulothoracic bursitis and (2) to compare outcomes between scapulothoracic bursectomy alone and bursectomy with scapuloplasty. We hypothesized that bursectomy with scapuloplasty would provide superior pain relief and functional improvement. MATERIALS AND METHODS: All cases of scapulothoracic débridement with or without scapuloplasty completed at a single academic center from 2007 through August 2020 were reviewed. Patient demographic characteristics, symptomatology data, physical examination findings, and corticosteroid injection response data were collected from the electronic medical record. Visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores were collected. Comparisons between the group undergoing bursectomy alone and the group undergoing bursectomy with scapuloplasty were made using the Student t test for continuous variables and the Fisher exact test for categorical variables. RESULTS: Thirty patients underwent scapulothoracic bursectomy alone, and 38 patients underwent bursectomy with scapuloplasty. Final follow-up data were available for 56 of 68 cases (82%). Final postoperative visual analog scale pain scores (3.4 ± 2.2 and 2.8 ± 2.2, respectively; P = .351), American Shoulder and Elbow Surgeons scores (75.8 ± 17.7 and 76.5 ± 22.5, respectively; P = .895), and Simple Shoulder Test scores (8.8 ± 2.3 and 9.5 ± 2.8, respectively; P = .340) were similar between the bursectomy-alone and bursectomy-with-scapuloplasty groups. CONCLUSION: Both arthroscopic scapulothoracic bursectomy alone and bursectomy with scapuloplasty are effective treatments for scapulothoracic bursitis. Operative time is shorter without scapuloplasty. In this retrospective series, these procedures showed similar outcomes regarding shoulder function, pain, surgical complications, and rates of subsequent shoulder surgery. Further studies with a focus on 3-dimensional scapular morphology may help optimize patient selection for each of these procedures.

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.

Active physical therapy does not improve outcomes after reverse total shoulder arthroplasty: a multi-center, randomized clinical trial.

OBJECTIVE: To compare range of motion (ROM) and patient-reported outcomes (PROs) between a structured home exercise program (HEP) and active, supervised physiotherapy (PT) after primary Reverse total shoulder arthroplasty (RTSA) by performing a multicenter randomized clinical trial. METHODS: Patients undergoing primary RTSA at 2 centers were randomized to either a HEP group, in which they were given a handout and a rope pulley, or a PT group, in which they were given a standardized prescription. Surgical technique and implants were standardized. At baseline, 6 weeks, 3 months, and 1 year postoperatively, we obtained American Shoulder and Elbow Surgeons scores, Western Ontario Osteoarthritis Scores, visual analogue scale for pain scores, and measured ROM via videotape. On video, ROM was then measured by blinded observers. At all study visits, patients were asked how many days per week they were in PT and how many days a week they completed HEP to determine compliance and crossover. An a priori power analysis suggested 29 patients per group, 56 patients total to detect a difference of 30° in active forward elevation with a power of 0.8 at a 2-sided alpha of 0.05. RESULTS: 89 patients were randomized, 43 to PT, and 46 to HEP. We obtained 1-year PRO follow-up on 83 patients (93%) and ROM follow-up on 73 patients (82%). Nine patients (20%) crossed over from HEP to PT and 2 patients (4%) crossed over from PT to HEP. Complications occurred in 13% of HEP and 17% of PT patients (P = .629). Using mixed models that account for baseline values, there were no significant differences between groups in PROs or ROM at final follow-up. CONCLUSION: In this 2-center, randomized clinical trial, there were no significant differences in patient outcomes or ROM between HEP and PT after RTSA. These findings suggest that it may not be necessary to recommend PT as a protocol for all patients after RTSA.

A stabilizing role of the glenoid labrum: the suction cup effect.

BACKGROUND: The glenoid labrum acts as a bumper, deepening glenoid concavity and amplifying the concavity-compression mechanism, and serves as the scapular attachment for glenohumeral ligaments. The role of the posterosuperior labrum in anteroinferior glenohumeral stability, and the role of the anterior labrum in posterior stability has been debated. The purpose of this study was to quantify the contribution of anteroinferior and posterosuperior labral tears to loss of glenohumeral stability in multiple directions. METHODS: Fourteen fresh-frozen cadaveric shoulders were tested on a custom stability ratio measurement apparatus. The peak force that was required to translate the humeral head in anterior, anteroinferior, posterior, and posteroinferior directions was measured under 5 conditions: intact labrum (n = 14), anteroinferior labral tear (n = 7), posterosuperior labral tear (n = 7), combined labral tear (n = 14), and no labrum (n = 14). The stability ratio was defined as the peak translational force divided by the compressive force. Within force-translation curves, we defined the suction cup effect as the force required to release the negative pressure created by an intact labrum. RESULTS: The suction cup effect was usually present with the intact labrum and always disappeared after removal of the labrum for anterior (100% vs. 0%) and posterior (86% vs. 0%) translations (P < .001). After creation of an anteroinferior labral tear, the stability ratio for posterior direction decreased (P < .001) and the suction cup effect disappeared (P < .001). After creation of a posterosuperior labral tear, stability ratios in the anterior and anteroinferior directions decreased (P ≤ .006) and the suction cup effect disappeared (P ≤ .015). The stability ratio for anterior and anteroinferior testing was more diminished by posterosuperior labral tears than anteroinferior labral tears, and the stability ratio for posterior testing was more diminished by anteroinferior labral tears than posterosuperior labral tears. CONCLUSION: Anteroinferior labral tears decreased posterior stability and posterosuperior labral tears decreased anterior and anteroinferior stability, largely because of loss of the suction cup effect.

Diagnosis and Management of Early Complications After Reverse Shoulder Arthroplasty.

Reverse shoulder arthroplasty has become the predominant shoulder arthroplasty procedure. Despite newer design modifications, complications still occur after reverse shoulder arthroplasty. Early complications include instability, acromial and scapular spine stress fractures, periprosthetic fractures, periprosthetic joint infections, and neurologic injury. It is important to discuss the diagnosis and management of these early complications.