Role of Delay Between Injury and Surgery on the Outcomes of Rotator Cuff Repair: A Systematic Review and Meta-analysis.

BACKGROUND: Outcomes of rotator cuff repair (RCR) are influenced by several well-described factors, but the role of delay from injury to surgery on the outcomes is not clear. PURPOSE: To assess the role of delay to surgery on the outcomes of RCR in the literature. STUDY DESIGN: Systematic review with meta-analysis; Level of evidence, 4. METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. All studies assessing outcomes after RCR-either retear rates or patient-reported outcome measures (PROMs)-and reporting delay to surgery were identified through June 2021 in PubMed, Embase, and Cochrane. Inclusion criteria consisted of traumatic injuries, mean age <65 years, minimum 6-month follow-up, and assessment of retear rates with radiologic examination or reporting of PROMs. Random-effect models were used to assess outcomes, reported in odds ratio (OR) or mean difference (MD) with 95% CIs. RESULTS: A total of 8118 patients were included from 33 studies, with a mean age of 59 years (range, 53-64) and mean follow-up of 3.0 years (range, 0.5-8.2), among whom 53% were male and 74% had dominant-side injury. Patients undergoing surgery >3 months after injury did not have significantly higher retear rates (OR, 1.1 [95% CI, 0.5 to 3.1]; P = .700), lower Constant-Murley score (MD, -6.2 [95% CI, -16.4 to 4.1]; P = .240), or lower ASES score (American Shoulder and Elbow Surgeons; MD, -12.9 [95% CI, -26.0 to -0.2]; P = .050) compared with those having surgery within 3 months. Similarly, delaying surgery for 6 months did not result in higher retear rates (OR, 1.7 [95% CI, 0.8 to 3.7]; P = .190) or lower PROMs. Delaying surgery for 1 year, however, led to an increased likelihood of retear when compared with <1 year (OR, 2.9 [95% CI, 2.1 to 4.0]; P < .001), and this was similar for the 2-year cutoff (OR, 5.9 [95% CI, 1.1 to 32.1]; P = .040). It was also noted that patients with an intact cuff at follow-up had a mean 3.9 months' shorter time from injury to surgery than patients with retear (95% CI, 1.0-6.8 months; P = .009). CONCLUSION: This systematic review with meta-analysis found that delaying rotator cuff surgery for 3 to 6 months did not lead to higher retear rates or inferior PROMs as compared with undergoing earlier surgery. However, delaying surgery for ≥1 year clearly resulted in higher retear rates after RCR. This study is limited by relying on retrospective studies, and larger prospective studies are needed to confirm these findings. REGISTRATION: CRD42021240720 (PROSPERO).

Ninety-day complication rate based on 532 Latarjet procedures in Dutch hospitals with different operation volumes.

BACKGROUND: In this study, we aimed to provide insight into the 90-day complication rates following the Latarjet procedure. Data from 2015 were collected from multiple hospitals in the Netherlands, with different volumes of Latarjet procedures. Our second aim was to examine which patient and surgical factors were associated with complications. METHODS: We conducted a retrospective chart review of 13 hospitals between 2015 and 2022. Data regarding complications within 90 days of Latarjet procedures were extracted. The effect of sex, age, body mass index (BMI), smoking, previous shoulder operations, fixation material, hospital volume, screw size, and operation time on the complication rate was assessed by multivariable logistic regression analysis. RESULTS: Of the 532 included patients, 58 (10.9%) had complications. The most common complications were material failure (n = 19, 3.6%) and nerve injury (n = 13, 2.4%). The risk of complications was lower for male patients than for female patients (odds ratio, 0.40; 95% confidence interval, 0.21-0.77; P = .006). Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time were not associated with complications. CONCLUSION: The 90-day complication rate after the Latarjet procedure was 10.9% and was higher in female patients than in male patients. Age, BMI, smoking, previous shoulder operations, type of fixation material, hospital volume, screw size, and operation time did not affect complication rates. We advise setting up a national registry to prevent under-reporting of complications.

Results of stemless shoulder arthroplasty: a systematic review and meta-analysis.

Stemless shoulder arthroplasty relies solely on cementless metaphyseal fixation and is designed to avoid stem-related problem such as intraoperative fractures, loosening, stress shielding or stress-risers for periprosthetic fractures.Many designs are currently on the market, although only six anatomic and two reverse arthroplasty designs have results published with a minimum of two-year follow-up.Compared to stemmed designs, clinical outcome is equally good using stemless designs in the short and medium-term follow-up, which is also the case for overall complication and revision rates.Intraoperative fracture rate is lower in stemless compared to stemmed designs, most likely due to the absence of intramedullary preparation and of the implantation of a stem.Radiologic abnormalities around the humeral implant are less frequent compared to stemmed implants, possibly related to the closer resemblance to native anatomy.Between stemless implants, several significant differences were found in terms of clinical outcome, complication and revision rates, although the level of evidence is low with high study heterogeneity; therefore, firm conclusions could not be drawn.There is a need for well-designed long-term randomized trials with sufficient power in order to assess the superiority of stemless over conventional arthroplasty, and of one design over another. Cite this article: EFORT Open Rev 2021;6:35-49. DOI: 10.1302/2058-5241.6.200067.

Capsulorraphy with Achilles allograft augmentation for shoulder instability in patients with Ehlers-Danlos syndrome.

BACKGROUND: Surgical management of shoulder instability in patients with Ehlers-Danlos syndrome (EDS) remains challenging secondary to the pathologic nature of their connective tissue. Allograft reconstruction of the shoulder capsule in EDS has the potential to increase stability by providing healthier connective tissue. The purpose of this study was to report the surgical technique and outcome of open capsulorraphy and augmentation of the anterior capsule with an Achilles tendon allograft in patients with shoulder instability in the setting of EDS. METHODS: Five shoulders (4 patients) with EDS and severe anteroinferior or multidirectional instability underwent open capsular shift combined with Achilles allograft augmentation of the anterior capsule. Patients were evaluated for pain, motion, recurrent instability, subjective shoulder value, American Shoulder and Elbow Surgeons score, complications, and reoperations. The mean follow-up time was 3.6 years (range, 2-5 years). RESULTS: Shoulder stability was restored in 4 of 5 (80%) shoulders. At the final follow-up, the mean subjective shoulder value and American Shoulder and Elbow Surgeons scores were 84 and 77.3, respectively. One shoulder developed recurrent posterior instability after an injury 1.6 years after the index procedure. The mean pain visual analog scale was 7 preoperatively and 2 at the most recent follow-up. Before surgery, all patients reported the use of narcotic pain medication, whereas at the most recent follow-up, only the one patient who had experienced recurrence reported moderate pain. Except for the shoulder that required revision surgery for posterior shoulder instability, there were no complications or other reoperations. CONCLUSION: Open capsulorraphy with Achilles allograft augmentation improved stability and pain in 4 of 5 shoulders with instability in the setting of EDS. In this small case series of patients with EDS, Achilles tendon allograft augmentation was safe and effective as a primary or revision surgical procedure for anterior shoulder instability. A larger patient cohort with longer follow-up is needed to confirm these findings.

Conversion to reverse shoulder arthroplasty fifty-one years after shoulder arthrodesis: A case report.

BACKGROUND: Patients with a shoulder arthrodesis generally experience restriction in range of motion and limitations in activities of daily living. In addition, up to one-third of the patients deals with serious peri scapular pain. The conversion of a shoulder arthrodesis in a reverse shoulder arthroplasty (RSA) has been described as an effective treatment to achieve better function and decreased pain, although literature is sparse. We present the case of a conversion from a painful shoulder arthrodesis to RSA, after a 51 years interval. CASE SUMMARY: A 71-year-old male presented with severe peri scapular pain and limited function 51 years after shoulder arthrodesis. Preoperative workup showed a normal bone stock of the glenoid and an intact axillary nerve, but atrophic posterior part of the deltoid muscle. The shoulder arthrodesis was successfully converted to RSA. Twelve months postoperative the patient was very satisfied. He has no pain at rest, nor with exercise and experienced definite improvements in activities of daily living, despite his limited range of motion. CONCLUSION: Conversion from shoulder arthrodesis to a RSA can be performed safely, with a high chance of peri scapular pain relief; even after a longstanding arthrodesis.

Suprapectoral versus subpectoral tenodesis for Long Head Biceps Brachii tendinopathy: A systematic review and meta-analysis.

BACKGROUND: Suprapectoral long head biceps (LHB) tenodesis and subpectoral LHB tenodesis are both commonly performed surgical procedures. Due to the more proximal position of the suprapectoral tenodesis site this technique may be accompanied with more postoperative pain in the bicipital groove and cramping pain in the biceps muscle. We hypothesized that subpectoral tenodesis is associated with a better clinical outcome than suprapectoral tenodesis. METHODS: A literature search was conducted in PubMed and Embase from January 2000 to July 2019 with the terms "biceps" and "tenodesis". Only comparing studies reporting on American Shoulder Elbow Score (ASES), VAS for anterior shoulder pain, Constant Murley Score (CMS), pain in the bicipital groove and Popeye deformity following suprapectoral and subpectoral tenodesis were included. Quality assessment of included articles was performed using the Coleman score. RESULTS: Seven comparative studies with 409 patients reporting the results of LHB suprapectoral and subpectoral tenodesis were included. A significant, but clinically irrelevant difference in ASES (mean difference 2.15) p=0.01 was observed. No significant difference in CMS (mean difference 0.09), VAS for anterior shoulder pain (mean difference 0.01), Popeye deformity (odds ratio 3.19) and persistent bicipital pain (odds ratio 2.66). The Coleman score ranged between 53 and 87. CONCLUSION: Based on this meta-analysis we found a significantly, though not clinically relevant difference in ASES in favour of subpectoral LHB tenodesis when compared with suprapectoral LHB tenodesis. Comparable results were found with regard to outcome scores, pain in the bicipital groove and avoiding a Popeye deformity.

New insights in the treatment of acromioclavicular separation.

A direct force on the superior aspect of the shoulder may cause acromioclavicular (AC) dislocation or separation. Severe dislocations can lead to chronic impairment, especially in the athlete and high-demand manual laborer. The dislocation is classified according to Rockwood. Types I and II are treated nonoperatively, while types IV, V and VI are generally treated operatively. Controversy exists regarding the optimal treatment of type III dislocations in the high-demand patient. Recent evidence suggests that these should be treated nonoperatively initially. Classic surgical techniques were associated with high complication rates, including recurrent dislocations and hardware breakage. In recent years, many new techniques have been introduced in order to improve the outcomes. Arthroscopic reconstruction or repair techniques have promising short-term results. This article aims to provide a current concepts review on the treatment of AC dislocations with emphasis on recent developments.

Once an arthrodesis, always an arthrodesis?

BACKGROUND: An arthrodesis of the shoulder is historically a solution for severe shoulder joint problems, for which no prosthetic solution is deemed possible. With the introduction of the reverse shoulder arthroplasty (RSA), which is intrinsically stable at the glenohumeral joint, it seems logical to consider conversion of a painful arthrodesis into a RSA, provided that the deltoid was not destroyed during the arthrodesis. METHODS: Four patients (2 men, 2 women; age 46-66 years) with a longstanding arthrodesis (5-11 years) visited our clinic with a painful shoulder (mainly around the scapula) with the request to provide more mobility. In all, the shoulder was fused in 60° to 80° of abduction, 20° to 40° of flexion, and 40° to 50° of internal rotation. All patients refused an osteotomy as treatment for the pain. A preoperative electromyelogram showed activity in at least the posterior or middle parts of the deltoid, or both. They were offered revision of arthrodesis to a reverse prosthesis. All complications, especially instability, were discussed. Surgery was performed through the previous deltopectoral scar. In 3 cases, the osteotomy was lateral to the original joint line, providing some lateralization. RESULTS: Follow-up was 22 to 60 months. The Constant-Murley score improved from 15-21 to 30-60. No dislocations occurred. All patients were satisfied, especially with the increased, although not impressive, rotations. Pain did not disappear but decreased considerably, from visual analog scale 8-10 to 0-4. CONCLUSION: Conversion into a RSA is a safe procedure in patients with a painful arthrodesis and grossly intact deltoid, providing better glenohumeral mobility (especially rotations), leading to improved patient satisfaction.

Isokinetic strength differences between patients with primary reverse and total shoulder prostheses: muscle strength quantified with a dynamometer.

BACKGROUND: Range of motion after total shoulder arthroplasty is better than after reverse shoulder arthroplasty, however with similar clinical outcome. It is unclear if this difference can only be found in the different range of motion or also in the force generating capacity. QUESTIONS: (1) are isokinetically produced joint torques of reverse shoulder arthroplasty comparable to those of total shoulder arthroplasty? (2) Does this force-generating capacity correlate with functional outcome? METHODS: Eighteen reverse shoulder arthroplasty patients (71years (SD 9years)) (21 shoulders, follow-up of 21months (SD 10months)) were recruited, 12 total shoulder arthroplasty patients (69years (SD 9years)) (14 shoulders, follow-up of 35months (SD 11months)). Pre- and post-operative Constant-Murley scores were obtained; two isokinetic protocols (ab-/adduction and ex-/internal rotations) at 60°/s were performed. FINDINGS: Twelve of 18 reverse shoulder arthroplasty patients generated enough speed to perform the test (13 shoulders). Mean ab-/adduction torques are 16.3Nm (SD 5.6Nm) and 20.4Nm (SD 11.8Nm). All total shoulder arthroplasty patients generated enough speed (14 shoulders). Mean ab-/adduction torques are 32.1Nm (SD 13.3Nm) and 43.1Nm (SD 21.5Nm). Only 8 reverse shoulder arthroplasty patients (9 shoulders) could perform ex-/internal rotation tasks and all total shoulder arthroplasty patients. Mean ex-/internal rotation torques are 9.3Nm (SD 4.7Nm) and 9.2Nm (SD 2.1Nm) for reverse shoulder arthroplasty, and 17.9Nm (SD 7.7Nm) and 23.5Nm (SD 10.6Nm) for total shoulder arthroplasty. Significant correlations between sub-scores: activity, mobility and strength and external rotation torques for reverse shoulder arthroplasty. Moderate to strong correlation for sub-scores: strength in relation to abduction, adduction and internal rotation torques for total shoulder arthroplasty. INTERPRETATION: Shoulders with a total shoulder arthroplasty are stronger. This can be explained by the absence of rotator cuff muscles and (probably) medialized center of rotation in reverse shoulder arthroplasty. The strong correlation between external rotation torques and post-operative Constant-Murley sub-scores demonstrates that external rotation is essential for good clinical functioning in reverse shoulder arthroplasty.

The active and passive kinematic difference between primary reverse and total shoulder prostheses.

BACKGROUND: Reverse shoulder arthroplasty (RSA) and total shoulder arthroplasty (TSA) effectively decrease pain and improve clinical outcome. However, indications and biomechanical properties vary greatly. Our aim was to analyze both active and passive shoulder motion (thoracohumeral [TH], glenohumeral [GH], and scapulothoracic [ST]) and determine the kinematic differences between RSAs and TSAs. METHODS: During 3 range-of-motion (ROM) tasks (forward flexion, abduction, and axial rotation), the motion patterns of 16 RSA patients (19 shoulders), with a mean age of 69 ± 8 years (range, 58-84 years), and 17 TSA patients (20 shoulders), with a mean age of 72 ± 10 years (range, 53-87 years), were measured. The mean length of follow-up was 22 ± 10 months (range, 6-41 months) for RSA patients and 33 ± 18 months (range, 12-87 months) for TSA patients. Kinematic measurements were performed with a 3-dimensional electromagnetic tracking device. RESULTS: All patients showed better passive than active ROM. This difference was significantly larger for RSA patients than for TSA patients (TH in sagittal plane, 20° vs 8° [P = .001]; GH in sagittal plane, 16° vs 7° [P = .003]; TH in scapular plane, 15° vs 2° [P < .001]; GH in scapular plane, 12° vs 0° [P < .001]; and ST in scapular plane, 3° vs -2° [P = .032]). This finding also showed that in the scapular plane, TSA patients showed hardly any difference between active and passive ROM. Furthermore, TSA patients had 16° to 17° larger active TH motion, 15° larger active GH motion, and 8° larger active ST motion compared with RSA patients. The GH-ST ratios showed similar figures for both types of prostheses. CONCLUSION: TSA patients have larger active TH motion because in the scapular plane, they completely use the possible GH motion provided by the prosthetic design. This larger active ROM in TSA patients only applies for elevation and abduction, not for axial rotation or passive ROMs.

Are shoulders with a reverse shoulder prosthesis strong enough? A pilot study.

BACKGROUND: It has been suggested that limited active ROM of reverse shoulder prostheses relates to lack of strength. However, the postoperative strength has not been quantified. QUESTIONS/PURPOSES: We therefore measured joint torques in patients with reverse shoulder prostheses and correlated torques with functional scores. METHODS: We recruited 33 patients (age, 72 ± 8 years) with a reverse prosthesis (37 shoulders, 21 primary and 16 revisions). We obtained Constant-Murley, DASH, and Simple Shoulder Test ([D]SST) scores, and performed two isokinetic protocols (abduction/adduction and external/internal rotation) at 60° per second. Minimum followup was 4 months (average, 23 months; range, 4-63 months). RESULTS: Twenty-three patients (24 shoulders; 13 primaries, 11 revisions) were able to perform at least one of the defined tasks. Mean abduction and adduction torques were 15 Nm ± 7 Nm and 16 Nm ± 10 Nm (19%-78% of normal shoulders). External and internal rotation tasks could be performed by only 13 patients (14 shoulders; nine primary, five revisions) generating 9 Nm ± 4 Nm and 8 Nm ± 3 Nm, respectively (13%-71% of normal shoulders). We found moderate correlations between Constant-Murley, DASH and (D)SST (D = Dutch translation) scores and abduction and external rotation. CONCLUSIONS: Patients with a reverse prosthesis had reduced strength when compared with normal values reported in the literature (only 65% of patients could perform the protocol). This effect was greatest for external rotation and might explain clinical outcomes with which a moderately strong relationship was observed. Our observations suggest limited strength is a major factor in reduced ROM.