Return to Sports in Patients Aged 50 Years or Younger After Robotic-Assisted Patellofemoral Arthroplasty: A 10-Year Experience Reporting High Clinical Benefits and High Patient Satisfaction With Return to an Active Lifestyle.

BACKGROUND: Limited data are available on return to sports and patient psychometric ratings of success after patellofemoral arthroplasty (PFA) in younger patients with high expectations to return to an active lifestyle. PURPOSE/HYPOTHESIS: The purpose of this article was to determine the role of PFA and its success in meeting patient expectations regarding the return to low-impact recreational sports and an active lifestyle in younger, active patients. It was hypothesized that PFA would allow younger patients to return to low-impact sports and an active lifestyle and achieve high patient psychometric ratings. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In this 10-year prospective study (2009-2018), robotic-assisted PFA was performed on 44 patients (32 women and 12 men; n = 51 consecutive knees), with a mean age of 37.2 years (range, 21-50 years). The follow-up rate was 98%, with a mean of 5.3 years (range, 2-9.3 years). Primary clinical outcomes were as follows: the validated Cincinnati Knee Rating System sports activity and symptom rating scales, patient psychometric ratings of the substantial clinical benefit (SCB), and the Patient Acceptable Symptom State (PASS). Secondary outcomes were the Cincinnati Knee Rating System occupational rating, visual analog pain scale, and the 12-Item Short Form Health Survey. Survivorship was defined by conversion to total knee replacement (TKR). RESULTS: Before PFA, 78% of patients (35/45 knees) were symptomatic and unable to perform recreational sports, with only 20% of patients (9/45 knees) performing some low-impact sports. After PFA, 80% of patients (36/45 knees) were able to perform low-impact sports, and 7% (3/45 knees) performed jumping-pivoting sports (P < .001). The SCB scored by the patient showed 87% of knees as good, very good, or normal. On the PASS analysis, 89% of patients (95% CI, 76%-96%) were "pleased," and 93% (95% CI, 82%-99%) would undergo surgery again. There were clinically relevant improvements in symptoms of pain, swelling, and giving way (P = .0001). Preoperatively, 91% of knees had moderate to severe pain with activities of daily living, and only 11% of knees had pain at the follow-up. Five of the 50 knees (10%) underwent TKR conversion with one patient lost to follow-up. CONCLUSION: PFA resulted in a high return of patients to low-impact sports with high SCB and PASS psychometric ratings. The robotic-assisted 3-dimensional preoperative planning allowed precise intraoperative trochlear implant alignment in knees with severe trochlear dysplasia. PFA is recommended as an alternative treatment in younger patients with end-stage symptomatic patellofemoral arthritis. REGISTRATION: NCT02738476 (ClinicalTrials.gov identifier).

Total shoulder arthroplasty in patients aged 80 years and older: a systematic review.

BACKGROUND: Elderly patients and their surgeons may eschew shoulder arthroplasty due to concerns over patient safety and longevity. The purpose of this study was to review the current literature evaluating the clinical and radiographic outcomes of shoulder arthroplasty performed in patients 80 years and older. METHODS: A literature search of the Embase, PubMed, Medline, and Cochrane databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating the outcomes of primary and revision anatomic (aTSA) and reverse (RSA) total shoulder arthroplasty in patients 80 years and older were included for analysis. RESULTS: A total of 15 studies evaluating 1685 primary aTSAs, 1170 primary RSAs, 69 RSAs performed for fracture, and 45 revision RSAs were included for review. The postoperative active forward flexion and external rotation ranged from 138° to 150° and 45° to 48° after aTSA and from 83° to 139° and 16° to 47° after RSA, respectively. Postoperative visual analog scale pain scores ranged from 0 to 1.8 after aTSA and from 0 to 1.4 after RSA. Ninety-day mortality ranged from 0% to 3%, and perioperative complications ranged from 0% to 32%. Late complications ranged from 5.6% to 24% for aTSA patients and 3.5% to 29% for patients undergoing RSA for all indications. Common complications included glenoid loosening (0%-18%) and rotator cuff tear (5.6%-10%) after aTSA and scapular notching (0%-40%) and scapular fracture (4%-9.4%) after RSA. Reoperation rates ranged from 0% to 6% after aTSA and from 0% to 13% after RSA. CONCLUSIONS: aTSA and RSA in this population are safe and effective, demonstrating low rates of perioperative mortality and reoperation, durability that exceeds patient longevity, satisfactory postoperative range of motion, and excellent pain relief. Late complication rates appear to be similar for aTSA and RSA.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears with and without Augmentation with a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement.

PURPOSE: The study objective was to compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant. METHODS: The study group comprised 24 patients (17 males) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 males) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion (ROM) and patient-reported outcomes (PROs) were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging (MRI) was obtained in 20/24 collagen implant patients and 17/24 control patients at minimum 6 months follow-up to assess tendon healing. RESULTS: American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in ROM and PROs were similar in both groups. MRI revealed intact repairs in 11/20 (55%) patients in the patch group and 9/17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty. CONCLUSIONS: Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Prosthetic shoulder arthroplasty in patients 40 years or younger: outcomes stratified by diagnosis and surgery.

BACKGROUND: The outcomes of patients 50-55 years old or younger undergoing prosthetic shoulder arthroplasty (PSA) may not generalize to younger patients. We report outcomes following PSA in a consecutive series of patients 40 years or younger. We hypothesize that total shoulder arthroplasty (TSA) provides better outcome and durability than resurfacing hemiarthroplasty (RHA). METHODS: Patients were stratified by diagnosis and surgical procedure performed, RHA or TSA. Active range of motion and self-assessed outcome were evaluated preoperatively and at final follow-up. RESULTS: Twenty-nine consecutive PSAs were identified in 26 patients, comprising 9 TSAs and 20 RHAs, with a minimum of 2-year follow-up. Twelve PSAs were performed for chondrolysis. Mean active forward elevation, abduction, external rotation, and internal rotation improved significantly (p<0.001 for all). Mean pain score improved from 6.3 to 2.1, Simple Shoulder Test from 4.0 to 9.0, and American Shoulder and Elbow Surgeons score from 38 to 75 (p<0.001 for all). Patients undergoing RHA and TSA had similar outcomes; but three RHAs required revision, two of these within 4 years of implantation. Four of five patients undergoing revision during the study period had an original diagnosis of chondrolysis. CONCLUSIONS: PSA in young patients provides substantial improvement in active range of motion and patient reported outcomes irrespective of diagnosis and glenoid management. However, patients undergoing RHA, especially for chondrolysis, frequently require subsequent revision surgery, so that RHA should be considered with caution in young patients and only after shared decision-making and counsel on the risk of early revision to TSA.

Reverse shoulder arthroplasty in patients 85 years and older is safe, effective, and durable.

BACKGROUND: Reverse shoulder arthroplasty (RSA) was originally indicated for older adults, but outcomes in the oldest patients have not been studied. The purpose of this study was to report on patients aged ≥85 years undergoing RSA. We hypothesized that RSA would be safe, effective, and durable. METHODS: Sixty-one RSAs were performed in 58 patients aged ≥85 years (16 patients aged ≥90 years); 40 RSAs were performed for arthritis with cuff deficiency, 14 were performed for proximal humeral fractures, and 7 were performed as revisions. Active range of motion and patient-reported outcomes, comprising the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale pain score, were obtained preoperatively and at final follow-up. Hospital length of stay, discharge disposition, and complications were recorded. Kaplan-Meier survivorship was computed with revision surgery or death as an endpoint. RESULTS: The mean age at RSA was 88.0 years. Mean forward elevation improved from 50.5° to 105.3°; abduction, from 48.7° to 96.1°; and external rotation, from 10.2° to 26.9° (P < .001 for all). Similarly, at a mean follow-up of 2.4 years, the visual analog scale pain score improved from 6.1 to 0.6; Simple Shoulder Test score, from 2.2 to 7.0; and American Shoulder and Elbow Surgeons score, from 33.6 to 78.2 (P < .001 for all). The mean length of stay was 3.6 days, and 15 patients were discharged home. Seven patients received a blood transfusion, and only 2 patients underwent a reoperation, neither of whom required explantation. DISCUSSION AND CONCLUSION: Improvements in active range of motion and patient-reported outcomes in our patients were comparable to those observed in younger cohorts and exceeded published minimal clinically important differences for most patients undergoing RSA for cuff deficiency. Additionally, to date, the patients in our study who died had lived with their RSA for a mean of 3.4 years and living patients had lived with their RSA for a mean of 4.3 years. RSA in patients aged ≥85 years is safe, effective, and durable for their remaining life expectancy. This information may help counsel older patients who are considering RSA, electively or for fractures.

Arthroscopic Evaluation and Treatment of Complications That Arise Following Prosthetic Shoulder Arthroplasty.

Arthroscopy may be used to diagnose symptomatic glenoid loosening following anatomic total shoulder arthroplasty (aTSA), and arthroscopic glenoid component removal may suffice as treatment for some patients. Arthroscopy may be used to diagnose shoulder prosthetic joint infection (PJI) following aTSA and reverse shoulder arthroplasty (RSA). Tissues are biopsied from multiple sites within the joint and the subdeltoid or subacromial space, and they are cultured for a minimum of 14 days. Postoperative adhesions arising after prosthetic shoulder arthroplasty (PSA) may be released arthroscopically. However, other problems contributing to shoulder stiffness such as component malpositioning or shoulder PJI require additional intervention. Arthroscopy may be used to repair select rotator cuff tears that arise acutely following aTSA, but chronic attritional tears do not heal after repair; therefore, revision to RSA often is needed. Many complications following PSA, such as infection, fixed instability, humeral component loosening, and major humeral or glenoid bone loss, are not adequately treated using arthroscopic techniques. However, arthroscopy following PSA may help to diagnose and treat other complications, even as the precise indications following aTSA and RSA remain unclear.

Reliability of a New Clinical Instrument for Measuring Internal and External Glenohumeral Rotation.

BACKGROUND: The shoulder plays a critical role in many overhead athletic activities. Several studies have shown alterations in shoulder range of motion (ROM) in the dominant shoulder of overhead athletes and correlation with significantly increased risk of injury to the shoulder and elbow. The purpose of this study was to measure isolated glenohumeral joint internal/external rotation (IR/ER) to determine inter- and intraobserver reliability of a new clinical device. HYPOTHESIS: (1) Inter- and intraobserver reliability would exceed 90% for measures of glenohumeral joint IR, ER, and total arc of motion; (2) the dominant arm would exhibit significantly increased ER, significantly decreased IR, and no difference in total arc of motion compared with the nondominant shoulder; and (3) a significant difference exists in total arc between male and female patients. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: Thirty-seven subjects (mean age, 23 years; range, 13-54 years) were tested by 2 orthopaedic surgeons. A single test consisted of 1 arc of motion from neutral to external rotation to internal rotation and back to neutral within preset torque limits. Each examiner performed 3 tests on the dominant and nondominant shoulders. Each examiner completed 2 installations. RESULTS: Testing reliability demonstrated that neither trial, installation, nor observer were significant sources of variation. The maximum standard deviation was 1.3° for total arc of motion and less than 2° for most other measurements. Dominant arm ER was significantly greater than nondominant arm ER (P = 0.02), and dominant arm IR was significantly less than nondominant arm IR (P = 0.00). Mean total rotation was 162°, with no significant differences in total rotation between dominant and nondominant arms (P = 0.34). Mean total arc of motion was 45° greater in female subjects. Differences in total arc of motion between male and female subjects was statistically significant (P < 0.00). CONCLUSION: This simple, clinical device allows for both inter- and intraobserver reliability measurements of glenohumeral internal and external rotation.

Glenohumeral chondrolysis: part I--clinical presentation and predictors of disease progression.

PURPOSE: The objective of this 2-part study is to report on the etiology, clinical findings, and predictors of disease progression (part I) and the results of treatment (part II) in a group of patients with glenohumeral chondrolysis. METHODS: Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed up since their initial presentation before arthroplasty (group 1), and 20 patients were referred either for management of complications arising after prosthetic arthroplasty or for evaluation only (group 2). RESULTS: Thirty-seven patients received an intra-articular pain pump (IAPP) delivering bupivacaine, and 3 patients had prominent suture anchors or tacks. Symptoms related to chondrolysis developed in patients at a mean of 9.8 months (range, 1 to 34 months) after the index procedure. Radiographs showed joint space obliteration in 30 of 40 patients at most recent follow-up or before arthroplasty. Of the patients receiving an IAPP delivering bupivacaine, the majority received 0.5% with epinephrine. Higher bupivacaine dose (P < .05) and female gender (P < .05) were associated with a longer interval to onset of symptoms. In addition, a shorter interval to onset of symptoms predicted the need for subsequent surgery (P < .05) and a shorter interval to second-look arthroscopy (P < .001). CONCLUSIONS: Post-arthroscopic glenohumeral chondrolysis is a devastating and rapidly evolving condition that most often strikes young patients. The use of IAPPs delivering local anesthetics should be abandoned because nearly all cases of glenohumeral chondrolysis in this series were associated with their use. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Glenohumeral chondrolysis: part II--results of treatment.

PURPOSE: The objective of this 2-part study is to report on the etiology and disease progression (part I) and results of treatment (part II) of glenohumeral chondrolysis. METHODS: Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed since their initial presentation and before prosthetic shoulder arthroplasty (group 1), and 20 patients were referred either for management of complications arising after shoulder arthroplasty or for evaluation only (group 2). All patients underwent standardized clinical and radiographic examination and completed shoulder-specific self-assessment questionnaires at initial presentation and after prosthetic shoulder arthroplasty for patients in group 1. RESULTS: Thirty of 40 patients underwent subsequent arthroscopy for debridement, chondroplasty, capsular release, or a combination of these procedures. Of these, 23 patients (77%) required additional surgery, comprising 18 prosthetic shoulder arthroplasties performed at a mean 13 months of follow-up (range, 3 to 33 months), as well as 5 repeated arthroscopies. At most recent follow-up, 15 of 20 patients in group 1 had undergone shoulder arthroplasty, with improvements in active forward elevation from 92.6° to 140.0° (P < .0001), active abduction from 81.6° to 131.3° (P < .0001), active external rotation from 22.1° to 49.3° (P < .0001), and active internal rotation from the gluteal region to the T12 spinous process (P < .001). Pain scores improved from 6.4 to 3.4 (P < .01), and self-assessed outcome also improved significantly. Twelve patients in group 2 underwent shoulder arthroplasty, so overall 27 of 40 patients (68%) underwent prosthetic shoulder arthroplasty for chondrolysis at a mean of 32 months (range, 9 to 66 months) after the index procedure. CONCLUSIONS: Postarthroscopic glenohumeral chondrolysis is a devastating condition that strikes young patients, responds poorly to arthroscopic interventions, and often requires shoulder arthroplasty within a few years. Patients can expect improved range of motion and outcome after shoulder arthroplasty, but pain relief is often incomplete. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The development of postoperative knee chondrolysis after intra-articular pain pump infusion of an anesthetic medication: a series of twenty-one cases.

BACKGROUND: Postoperative chondrolysis in the knee joint caused by continuous intra-articular pain pumps infusing bupivacaine is a serious complication that severely affects function. We report the clinical course of a series of twenty-one patients who were referred to our clinic with this complication. METHODS: A physical examination and a review of medical records were conducted. The condition of the articular cartilage was determined from operative notes, photographs, magnetic resonance images, and radiographs. Knee function was assessed with the Cincinnati Knee Rating System. RESULTS: The study group included eighteen female and three male patients ranging in age from fourteen to forty-two years. The index procedures, all done elsewhere, included eighteen anterior cruciate ligament reconstructions, one meniscal repair, one arthroscopy, and one tibial tubercle osteotomy. An intra-articular high-flow-volume pump (200 to 270 mL) was used in ten patients, and a low-flow-volume pump (90 to 120 mL) was used in ten patients; the flow rate in the remaining patient was not documented. The devices used 0.5% bupivacaine in twenty knees and 0.25% in one knee, with 1:200,000 epinephrine added in eleven knees. Knee symptoms affecting daily activities occurred at a mean of 9 ± 7 months after the index procedure. Extensive chondrolysis with loss of articular cartilage of all three knee compartments occurred in six knees. In ten knees, two compartments were affected, and in five knees, one compartment was abnormal. All patients had marked limitations and pain with daily activities, and nineteen patients underwent forty-one subsequent surgical procedures. CONCLUSIONS: Severe postoperative knee chondrolysis occurred after the use of a high or low-flow-volume pump infusing intra-articular bupivacaine, producing disabling knee symptoms. A variety of operative procedures failed to alleviate symptoms. Although this study does not define the incidence of knee chondrolysis after intra-articular bupivacaine pain-pump infusion, the severe complications reported here warrant its use to be contraindicated.

Predictors of outcome after nonoperative and operative treatment of adhesive capsulitis.

BACKGROUND: Few studies regarding adhesive capsulitis have concurrently evaluated nonoperative and operative treatment. PURPOSE: The objectives were to evaluate the efficacy of operative and nonoperative treatment of adhesive capsulitis and to determine predictors of clinical outcome. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: At minimum 24 months' follow-up, 85 patients underwent self-assessment using the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) score, including 24 patients treated operatively. RESULTS: Mean number of yes responses on the SST improved from 4.0 ± 2.7 at initial presentation to 9.9 ± 2.8 at final follow-up (P < .0001). Patients who received nonoperative treatment and patients who underwent surgery demonstrated similar improvements on the SST. For the entire cohort, forward elevation and external rotation at the side improved from 119° ± 20° to 152° ± 15° and from 29° ± 18° to 46° ± 11° (P < .0001), respectively, between initial presentation and discharge from treatment. Internal rotation to the back improved from the gluteal area to the thoracolumbar junction (P < .0001). Improvements in forward elevation and external rotation were greater for patients undergoing surgery. After nonoperative treatment, patients with diabetes had a lower final SST than patients without diabetes (P < .05). For the entire cohort, initial SST predicted final SST (P < .05), and a shorter duration of symptoms predicted a higher final ASES score (P < .05). Younger patients (P < .001) and those with a lower initial SST (P < .05) were more likely to undergo surgery. CONCLUSIONS: A multimodal nonoperative treatment program is effective for most patients with adhesive capsulitis. Patients who do not improve, including those with diabetes, respond well to manipulation and arthroscopic release. Residual motion deficits at discharge from treatment do not appear to affect longer-term clinical outcome.

Early Results of Concurrent Arthroscopic Repair of Rotator Cuff and Type II Superior Labral Anterior Posterior Tears.

BACKGROUND: Recent reports on concurrent arthroscopic rotator cuff and type II superior labral anterior posterior (SLAP) repair have raised concerns over postoperative stiffness and patient satisfaction. However, it is unclear if the observed stiffness relates to the repair of degenerative SLAP tears in older adults, the surgical technique, the postoperative rehabilitation, or to a combination of these factors. PURPOSE: The purpose of this study was to evaluate the outcome and repair integrity of concurrent arthroscopic rotator cuff and type II SLAP repair. STUDY DESIGN: Case series. METHODS: Of 11 patients identified, 7 had a full-thickness rotator cuff tear and 4 had a high-grade partial thickness tear that was completed. A cannula placed through the rotator cuff tear improved the trajectory for posterior suture anchor placement during SLAP repair. Postoperative rehabilitation employed continuous passive motion to prevent stiffness. RESULTS: At minimum of 1-year follow-up, mean yes responses on the Simple Shoulder Test improved from 5.4 to 10.7 (out of 12; P < .01), and mean American Shoulder and Elbow Surgeons scores improved from 40 to 87 (out of 100; P < .01). Mean forward elevation improved from 148° to 161° (P < .01) and external rotation from 58° to 67° (P < .01). Magnetic resonance imaging, obtained at most recent follow-up in 10 patients, demonstrated a healed SLAP tear in all patients and a persistent rotator cuff defect in 1 patient. CONCLUSIONS: Arthroscopic rotator cuff repair can be successfully combined with type II SLAP repair in relatively young patients who have sustained traumatic injury to their shoulders. Allowing early passive motion may help prevent postoperative stiffness without compromising rotator cuff healing.