Quantifying Threshold Scores for Patient Satisfaction After Massive Rotator Cuff Repair for the Interpretation of Mid-Term Patient-Reported Outcomes.

PURPOSE: To establish minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) values for 4 patient-reported outcomes (PROs) in patients undergoing arthroscopic massive rotator cuff repair (aMRCR): American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), Veterans Rand-12 (VR-12) score, and the visual analog scale (VAS) pain. In addition, our study seeks to determine preoperative factors associated with achieving clinically significant improvement as defined by the MCID and PASS. METHODS: A retrospective review at 2 institutions was performed to identify patients undergoing aMRCR with minimum 4-year follow-up. Data collected at the 1-year, 2-year, and 4-year time points included patient characteristics (age, sex, length of follow-up, tobacco use, and workers' compensation status), radiologic parameters (Goutallier fatty infiltration and modified Collin tear pattern), and 4 PRO measures (collected preoperatively and postoperatively): ASES score, SSV, VR-12 score, and VAS pain. The MCID and PASS for each outcome measure were calculated using the distribution-based method and receiver operating characteristic curve analysis, respectively. Pearson and Spearman coefficient analyses were used to determine correlations between preoperative variables and MCID or PASS thresholds. RESULTS: A total of 101 patients with a mean follow-up of 64 months were included in the study. The MCID and PASS values at the 4-year follow-up for ASES were 14.5 and 69.4, respectively; for SSV, 13.7 and 81.5; for VR-12, 6.6 and 40.3; and for VAS pain, 1.3 and 1.2. Greater infraspinatus fatty infiltration was associated with failing to reach clinically significant values. CONCLUSIONS: This study defined MCID and PASS values for commonly used outcome measures in patients undergoing aMRCR at the 1-year, 2-year, and 4-year follow-up. At mid-term follow-up, greater preoperative rotator cuff disease severity was associated with failure to achieve clinically significant outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Remote visual estimation of shoulder range of motion has generally high interobserver reliability but limited accuracy.

Background: Surgeon visual estimation of shoulder range of motion (ROM) is commonplace in the outpatient office setting and routinely reported in clinical research, but the reliability and accuracy of this practice remain unclear. The purpose of this study is to establish the reliability and accuracy of remote visual estimation of shoulder ROM in healthy volunteers and symptomatic patients among a large group of shoulder surgeons. Our hypothesis is that remote visual estimation would be reliable and accurate compared with the digital goniometer method. Methods: Fifty shoulder surgeon members of the PacWest Shoulder and Elbow Society independently determined the active shoulder forward flexion (FF), internal rotation at 90° abduction (IR90), external rotation at 90° abduction, external rotation at the side , and maximal spinal level reached with internal rotation (IRspine) through visual estimation of video recordings taken from 10 healthy volunteers and 10 symptomatic patients. Variations in measurements were quantified using the interobserver reliability through calculation of the intraclass correlation coefficient. Accuracy was determined through comparison with digital goniometer measurements obtained with an on-screen protractor application using Bland-Altman mean differences and 95% limits of agreement. Results: The interobserver reliability among examiners showed moderate to excellent correlation, with intraclass correlation coefficient ranging from 0.768 to 0.928 for the healthy volunteers and 0.739 to 0.878 for the symptomatic patients. Accuracy was limited, with upper limits of agreement exceeding the established minimal clinically important differences (MCIDs) for FF (20° vs. MCID of 14°) and IR90 (25° vs. 18°) in the healthy volunteers and for FF (33° vs. 16°), external rotation at 90° abduction (21° vs. 18°), and IR90 (31° vs. 20°) in the symptomatic patients. Conclusion: Despite generally high intersurgeon reliability in the visual estimation of shoulder ROM, there was questionable accuracy when compared to digital goniometer measurements,with measurement errors often exceeding established MCID values. Given the potential implications for the clinical response to treatment and the significance of research findings, the adoption of validated instruments to measure ROM and the standardization of examination procedures should be considered.

Rip-Stop Fixation Constructs for Rotator Cuff Repair.

In arthroscopic rotator cuff repair, poor tendon quality, medially based tears, lateral tendon loss, or limited tendon mobility can all preclude the use of double-row suture constructs, presenting a challenge in achieving secure fixation and tendon-to-bone healing. Rip-stop suture configurations can be used in these settings to improve resistance to tissue cutout and provide enhanced biomechanical characteristics compared with standard single-row repairs. The load-sharing rip-stop technique uses 2 double-loaded medial suture anchors, which are placed adjacent to the articular margin, and 1 rip-stop suture tape, which is independently secured to bone with 2 lateral knotless anchors. The load-sharing rip-stop technique has been shown to improve ultimate load to failure by 1.7 times compared with a single-row repair. Clinically, this technique has been associated with a 53% healing rate of large and massive rotator cuff tears, compared with only 11% healing when using single-row repair. A completely knotless variation rip-stop configuration also has been described and shown to be biomechanically equivalent to a single-row repair with triple-loaded anchors. For surgeons desiring a single-row repair only, the knotless rip-stop therefore presents an advantage by eliminating the need for knot-tying and decreasing operative time.

Secondary Rotator Cuff Insufficiency After Anatomic Total Shoulder Arthroplasty.

¼ Secondary rotator cuff insufficiency is a challenging complication after anatomic total shoulder arthroplasty.¼ Acute tears may be amenable to open or arthroscopic repair in some instances.¼ Chronic attritional tears are best managed with revision to reverse shoulder arthroplasty, especially in the elderly.¼ Increased glenoid inclination, larger critical shoulder angle, oversized humeral components, thicker glenoid components, and rotator cuff muscle fatty infiltration have all shown to contribute to tear risk.

Arthroscopic Repair of Massive Rotator Cuff Tears Leads to Functional Improvement in Most Patients at 4-Year Follow-up.

Purpose: To assess functional outcomes and healing 4 years after arthroscopic repair of massive rotator cuff tears (MRCTs). Methods: We conducted a retrospective study of patients who underwent arthroscopic rotator cuff repair of an MRCT-defined as a complete 2-tendon tear or a tear greater than 5 cm in any dimension-performed by 2 surgeons at different institutions between January 2015 and December 2018. At a minimum of 4 years postoperatively, patient-reported outcomes collected included the visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12 (VR-12) score, and Subjective Shoulder Value (SSV) score. Repair technique and concomitant procedures were also gathered. Tendon healing was evaluated via ultrasound at final follow-up. Results: Functional outcomes were available for 101 patients at a mean of 63.6 ± 8.8 months (range, 48-82 months) postoperatively. Mean ASES scores improved from 40.1 to 78 (P < .001); VR-12 scores, from 37.1 to 47.7 (P < .001); and SSV scores, from 36.7 to 84.6 (P < .001). Forward flexion improved from 126° to 144° (P = .001), external rotation remained unchanged (from 47° to 44°, P = .268), and internal rotation improved by 2 spinal levels (from L4 to L2, P = .0001). Eighty-eight percent of patients (89 of 101) were satisfied with the procedure, and only 5% underwent reverse shoulder arthroplasty within the study period. Among the 39 patients who underwent postoperative ultrasound to assess healing, 56% showed complete tendon healing. There was no difference in healing or outcomes according to tear pattern. Additionally, tendon healing did not affect outcomes. Conclusions: Arthroscopic repair of MRCTs leads to functional improvements and patient satisfaction in most cases at 4-year follow-up. The rates of patients achieving the minimal clinically important difference were 77.5%, 87.6%, 59.7%, and 80.6% for the ASES score, SSV score, VR-12 score, and visual analog scale pain score, respectively. Complete tendon healing is difficult to achieve but does not appear to limit functional improvements. Level of Evidence: Level IV, therapeutic case series.

Patient-reported outcome tools and baseline scores vary by country and region for arthroscopic repair of massive rotator cuff tears: a systematic review.

Background: Different patient-reported outcome (PRO) tools are used in patients with arthroscopic rotator cuff repair (ARCR) which complicates outcome comparisons. The purpose of this systematic review was to compare PRO usage and baseline scores across world regions and countries in patients with ARCR of massive rotator cuff tears (MRCT). Methods: A systematic review was performed on ARCR for MRCT. The search was conducted from September to November of 2022 using the MEDLINE database for articles published in the last 15 years. Thirty-seven articles were included after initial screening and full-text review. In each article, PRO usage, baseline scores, and country of origin were collected. PRO usage was reported in percentages and baseline scores were normalized for each region to facilitate comparisons. Normalization was performed using the PRO means from each article. These averages were converted to fractions using the worst and best possible scores. These were combined into a single numerical value, expressed as a decimal from 0 to 1, using the total sample size for each tool per region. Values closer to 0 represent worse functional outcomes. Results: Thirty-two percent (n = 12) of articles were from Asia, 43.2% (n = 16) from Europe, 5.4% (n = 2) from the Middle East, and 18.9% (n = 7) from North America. The most commonly reported PRO tools were American Shoulder and Elbow Surgeons (ASES) in 19 papers, Constant-Murley Score (CMS) in 26 papers, Visual Analog Scale for pain (VAS) in 19 papers, and University of California in Los Angeles (UCLA) in 11 papers. ASES was reported in 51% of articles with 63% being from Asia (n = 12) compared to 21% from North America (n = 4). CMS was reported in 70% of studies with 58% being from Europe. Upon normalization, the preoperative score ranged from 0.30 to 0.44. Europe (0.39), and North America (0.40) showed similar scores. The lowest and highest scores were seen in the Middle East (0.3) and Asia (0.44) respectively. Conclusion: There is no standardized method to report outcomes in patients undergoing ARCR for MRCT. Great variation in usage exists in PROs which complicates data comparison between world regions. With normalization, baseline scores where similar among Asia, North America, and Europe, and lowest in the Middle East.

Female Sex and Higher Infraspinatus Fatty Infiltration Are Linked to Dissatisfaction at a Minimum Follow-Up of 4 Years after Arthroscopic Repair of Massive Rotator Cuff Tears.

Purpose: To evaluate patient satisfaction at a minimum of 4 years after arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCT), to identify preoperative and intraoperative characteristics associated with satisfaction, and to compare clinical outcomes between satisfied and dissatisfied patients. Methods: A retrospective review on prospectively collected data was conducted on ARCRs of MRCTs performed at 2 institutions between January 2015 and December 2018. Patients with a minimum 4-year follow-up, preoperative and postoperative data, and primary ARCR of MRCTs were included for analysis. Patient satisfaction was analyzed according to patient demographics, patient-reported outcome measures (American Shoulder and Elbow Surgeons score [ASES], visual analog scale [VAS] for pain, Veteran Rands 12-item health survey [VR-12], and Subjective Shoulder Value [SSV]), range of motion (forward flexion [FF], external rotation [ER], and internal rotation [IR]), tear characteristics (fatty infiltration, tendon involvement, and tear size), and clinical significant measures (minimal clinical important difference [MCID], substantial clinical benefit [SCB], and patient-acceptable symptomatic state [PASS]) for ASES and SSV. Rotator cuff healing was also assessed with ultrasound in 38 patients at final follow-up. Results: A total of 100 patients met the study's criteria. Overall, 89% of patients were satisfied with ARCR of a MRCT. Female sex (P = .007) and increased preoperative infraspinatus fatty infiltration (P = .005) were negatively associated with satisfaction. Those in the dissatisfied cohort had significantly lower postoperative ASES (80.7 vs 55.7; P = .002), VR-12 (49 vs 37.1; P = .002), and SSV scores (88.1 vs 56; P = .003), higher VAS pain (1.1 vs 4.1; P = .002) and lower postoperative range of motion in FF (147° vs 117°; P = .04), ER (46° vs 26°; P = .003), and IR (L2 vs L4; P = .04). Rotator cuff healing did not have an influence on patient satisfaction (P = .306). Satisfied patients were more likely to return to work than dissatisfied patients (97% vs 55%; P < .001). Conclusions: Nearly 90% of patients who undergo ARCR for MRCTs are satisfied at a minimum 4-year follow-up. Negative preoperative factors include female sex and increased preoperative infraspinatus fatty infiltration, but no association was observed with rotator cuff healing. Furthermore, dissatisfied patients were less likely to report a clinically important functional improvement. Level of Evidence: Level IV, prognostic case series.

A Step-by-Step Approach to Arthroscopic Repair of Massive Rotator Cuff Tears.

Arthroscopic repair of massive rotator cuff tears can be technically challenging but is achievable in many cases. Performing adequate releases are important for successful tendon mobility and avoiding excessive tension in the final repair, thus restoring the native anatomy and biomechanics. This Technical Note provides a step-by-step approach to release and mobilize massive rotator cuff tears to or near anatomical tendon footprints.

Arthroscopically Assisted Tensionable Cerclage Reconstruction of an Acromioclavicular Separation With Combined Fixation of the Coracoclavicular and Acromioclavicular Ligaments.

A variety of surgical techniques are currently available to manage high-grade acromioclavicular (AC) separations, including hook plates/wires, nonanatomic ligament reconstruction, and anatomic cerclage with or without biological augmentation. Traditional reconstructions focused on the coracoclavicular ligaments alone and often were associated with high rates of recurrent deformity. Biomechanical and clinical data have suggested that additional fixation of the AC ligaments is beneficial. This Technical Note describes an arthroscopically assisted approach for combined reconstruction of the coracoclavicular and AC ligaments with a tensionable cerclage.

Short-term functional outcomes of reverse shoulder arthroplasty following three-dimensional planning is similar whether placed with a standard guide or patient-specific instrumentation.

BACKGROUND: Preoperative assessment of the glenoid and surgical placement of the initial guidewire are important in implant positioning during reverse total shoulder arthroplasty (rTSA). Three-dimensional (3D) computed tomography and patient-specific instrumentation (PSI) have improved the placement of the glenoid component, but the impact on clinical outcomes remains unclear. The purpose of this study was to compare short-term clinical outcomes after rTSA based on an intraoperative technique for central guidewire placement in a cohort of patients who had preoperative 3D planning. METHODS: A retrospective matched analysis was performed from a multicenter prospective cohort of patients who underwent rTSA with preoperative 3D planning and a minimum of 2-year clinical follow-up. Patients were divided into 2 cohorts based on the technique used for glenoid guide pin placement: (1) standard manufacture guide (SG) that was not customized or (2) PSI. Patient-reported outcomes (PROs), active range of motion, and strength measures were compared between the groups. The American Shoulder and Elbow Surgeons score was used to assess the minimum clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state. RESULTS: One hundred seventy-eight patients met the study criteria: 56 underwent SGs and 122 underwent PSI. There was no difference in PROs between cohorts. There were no significant differences in the percentage of patients who achieved an American Shoulder and Elbow Surgeons minimum clinically important difference, substantial clinical benefit, or patient acceptable symptomatic state. Improvements in internal rotation to the nearest spinal level (P < .001) and at 90° (P = .002) were higher in the SG group, but likely explained by differences in glenoid lateralization used. Improvements in abduction strength (P < .001) and external rotation strength (P = .010) were higher in the PSI group. CONCLUSION: rTSA performed after preoperative 3D planning leads to similar improvement in PROs regardless of whether an SG or PSI is used intraoperatively for central glenoid wire placement. Greater improvement in postoperative strength was observed with the use of PSI, but the clinical significance of this finding is unclear.

Soft Anchors for Rotator Cuff Repair: A Review.

¼: All-suture anchors or so-called "soft" anchors, initially adapted for labral repairs, have increased in popularity for use in rotator cuff repair because of their smaller size, decreased occupation of the footprint, improved points of fixation, ease of use, and ease of revision. ¼: In limited series, soft anchors have demonstrated equivalent biomechanical and clinical performance compared with hard body anchors for rotator cuff repair. ¼: Perianchor cyst formation can occur with both hard body and soft anchors. ¼: Biomechanical and clinical data support aiming for vertical angles of insertion for soft anchors.

Arthroscopic Remplissage for the Treatment of Anterior Shoulder Instability: Current and Evolving Concepts.

➢: A Hill-Sachs lesion (HSL) is a compression fracture on the posterolateral humeral head that can increase the risk of recurrent shoulder instability after isolated arthroscopic Bankart repair. ➢: Remplissage involves capsulotenodesis of the infraspinatus tendon and posterior capsule into the HSL to prevent its engagement with the glenoid rim through extra-articular conversion and restraint against humeral head anterior translation. ➢: The glenoid track concept can be applied preoperatively and intraoperatively to evaluate risk of recurrence and help direct clinical management options for recurrent shoulder instability. ➢: Recent literature supports expanding indications for remplissage to include patients with on-track HSLs who are at increased risk of recurrence including collision athletes, military personal, and patients with joint hyperlaxity. ➢: New techniques and suture constructs have demonstrated improved biomechanical strength while avoiding the need to access the subacromial space.