One- and 2-Year American Shoulder and Elbow Surgeons Scores Do Not Vary Significantly After Arthroscopic Rotator Cuff Repair: A Prospective Multicenter Analysis of 1,567 Patients.

PURPOSE: To evaluate whether there are clinically significant changes in patient-reported outcomes between 1 and 2 years' postoperatively after arthroscopic rotator cuff repair (RCR). METHODS: A retrospective analysis of prospective, multicenter registry was queried for all patients who underwent RCR. Patients with preoperative, 6-month, 1-year, and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. We evaluated mean postoperative ASES scores, Δ (change from preoperative) ASES, and the %MOI (% maximum outcome improvement). We also evaluated achievement of clinically significant outcomes (CSOs) for the ASES score, including the minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state. RESULTS: There were 1,567 patients with complete data through 2-year follow-up. There were small differences in achievement of CSOs from 1 to 2 years: 88% to 91% for MCID, 81% to 83% for substantial clinical benefit, and 65% to 71% for patient-acceptable symptom state. There were statistically significant differences from 1 to 2 years in mean ASES (87 to 88, P < .001), Δ ASES (37 to 39, P < .001), and %MOI (72% to 76%, P < .001); however, these changes were well below the MCID of 11.1. From 1 to 2 years, the mean ASES improved only 1.7 points (P < .001). At 1 year, patients achieved, on average, 97% of their 2-year ASES. CONCLUSIONS: Both patient-reported outcomes and achievement of CSOs show small differences at 1 and 2 years after RCR. Given the large sample size, there were statistical differences, but these are unlikely to be clinically relevant. LEVEL OF EVIDENCE: Level IV, case series.

Preoperative Patient Reported Outcomes Predict Postoperative Clinical Outcomes Following Rotator Cuff Repair.

PURPOSE: The purpose of this study was to determine whether preoperative patient-reported outcomes (PROs) predict postoperative PROs and satisfaction following rotator cuff repair. METHODS: We retrospectively identified patients who underwent a primary rotator cuff repair at a single institution. A receiver operating characteristics (ROC) analysis was used to reach a preoperative American Shoulder and Elbow Surgeons (ASES) score threshold predictive of postoperative ASES and satisfaction scores. We evaluated patients above and below the ROC threshold by comparing their final ASES scores, ASES change (Δ) from baseline, percent maximum outcome improvement (%MOI), and achievement of minimum clinically important differences (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS). Fischer exact tests were used to analyze categorical data, while continuous data were analyzed using t-test. RESULTS: A total of 348 patients who underwent rotator cuff repair were included in this study. The preop ASES value predictive of achieving SCB was 63 (area under the curve [AUC], 0.75; 95% confidence interval: 58-67; P < .001). Patients with preoperative ASES less than 63 were significantly more likely to achieve MCID (odds ratio [OR]: 4.7, P < .001) and SCB (OR:6.1, P < .001) and had significantly higher %MOI (63% vs 41%; P = 0.003) and Δ ASES scores (36 vs 12; P < .001). However, patients with preop ASES scores above 63 had significantly higher final ASES scores (86 vs 79; P = .003), were more likely to achieve PASS (59% vs 48%; P = .045), and had higher satisfaction scores (7.4 vs 6.7; P = .024). CONCLUSIONS: Patients with high preop ASES scores achieve less relative improvement; however, these patients may be more likely to achieve PASS and may have higher satisfaction scores postoperatively. LEVEL OF EVIDENCE: Level III, retrospective comparative prognostic trial.

Editorial Commentary: Repair Is Efficacious for Acute Rotator Cuff Tears in Patients Over 65 Despite Advanced Age, and Early Repair Is Better.

Although indications for rotator cuff repair are still controversial, common practice is to be more aggressive with surgery as a first-line treatment in patients with acute rotator cuff tears. Both functional outcomes and healing are better with earlier repair, and a healed tendon limits the progression of permanent degenerative changes, including tear progression, fatty infiltration, and progression to cuff tear arthropathy. But what about elderly patients? For those that are physically and medically fit for surgery, there may still be benefit to earlier surgical repair. For those not physically or medically fit for surgery, or those who decline, a short trial of conservative care and repair for those who fail with conservative treatment is still efficacious.

Acute, Traumatic Rotator Cuff Tears Have Smaller Critical Shoulder Angles Than Degenerative Tears.

PURPOSE: To determine whether the critical shoulder angle (CSA) in acute, traumatic rotator cuff tears (RCTs) is consistent with the previously described CSA in chronic degenerative RCTs. METHODS: We performed a multicenter retrospective analysis of 134 patients presenting to 5 surgeons fellowship trained in shoulder and elbow or sports. Preoperative imaging was used to measure the CSA and tear characteristics. Patients were included if they had acute, traumatic full-thickness RCTs documented on advanced imaging and had preoperative Grashey radiographs. Patients were excluded if they had any history of shoulder pain, injury, surgery, or treatment prior to the current episode; were overhead athletes; or had fatty infiltration greater than Goutallier grade 1 on imaging. RESULTS: The mean CSA was 33.5° (standard deviation, 4.1°), and 60% of tears had a CSA of less than 35°, much below the mean of 38.0° and the threshold of greater than 35° in degenerative RCTs. The mean age was 58 years, and 70% of patients were men. Overall, 60% of tears involved the subscapularis, 49% of tears occurred in patients aged 60 years or older, and 18% of patients sustained a dislocation. Older age (ß = 0.316, P = .003) and male sex (ß = 5.532, P = .025) were predictive of tear size, and older age (ß = 0.229, P = .011) and biceps avulsion (ß = 8.822, P = .012) were predictive of tear retraction. CONCLUSIONS: Acute, traumatic RCTs have CSAs that are 5° smaller than those of degenerative tears, and the majority (60%) have CSAs that are below the threshold consistent with degenerative RCTs. The majority of traumatic tears (60%) involve the subscapularis. CLINICAL RELEVANCE: The study findings suggest that a traumatic tear is not simply the acute failure of a degenerative tendon and that it represents a distinct pathologic entity. These findings support current practice of treating traumatic RCTs differently than degenerative RCTs.

Using the Greater Tuberosity as a Reference for Placement of Proximal Humerus Plates Leads to a High Rate of Calcar Screw Malposition.

OBJECTIVES: Achieving calcar fixation is critical to minimize the failure of proximal humerus fractures repaired with proximal humeral locking plates (PHLPs). Many operative technique manuals reference the greater tuberosity (GT) for plate placement. The objective of this study was to examine the accuracy of calcar screw placement when PHLPs were placed based on distance from the GT. METHODS: Twenty cadaveric specimens were acquired representing a height distribution across the US population. Thirteen different PHLPs were applied. A drill bit was placed through the designated calcar screw hole and measured on radiographs, with the inferior 25% of the head representing an ideal placement. RESULTS: Three hundred fifty constructs were studied. In 28% of the specimens, the calcar screw was misplaced. In 20% of the specimens, it was too low, whereas in 8%, it was too high. The calcar screw missed low in 30% of patients shorter than 5 feet, 5.5 inches versus 8% of taller patients ( P = 0.007). It missed high in 13% of taller patients versus 2% of shorter patients ( P = 0.056). Calcar screws in variable-angle plates missed 0% of the time, whereas those in fixed-angle plates missed 36% of the time ( P = 0.003). CONCLUSIONS: Placement of PHLPs based on distance from the GT results in unacceptable position of the calcar screw 28% of the time and up to 36% in fixed-angle plates. This could be further compounded if the GT is malreduced. Current technique guide recommendations result in an unacceptably high rate of calcar screw malposition.

Management of Acute Rotator Cuff Tears.

Acute, traumatic rotator cuff tears typically occur in younger patients with a fall on an outstretched hand, grabbing an object to catch oneself when falling, or a glenohumeral dislocation. These tears are best evaluated with MRI. Partial-thickness tears may be managed nonoperatively with physical therapy, NSAIDs, and injections. Full-thickness tears in most patients should be managed with surgical repair as soon as possible, with better outcomes shown when repaired within 4 months of injury.

Two-Incision Distal Biceps Repair with Cortical Button: A Technique to Improve Supination Strength.

Tears of the distal biceps are common, and nonoperative treatment results in significant loss of supination strength. Surgery is indicated for most patients to restore this supination strength. Both 1- and 2-incision techniques are successful, but each has its own advantages and disadvantages. We believe the 2-incision technique better restores the anatomic attachment site of the tendon, which leads to better supination strength and has a lower rate of neurologic injury. Although it does have a slightly higher risk of synostis, this can be mitigated by routine prophylaxis with NSAIDs. Augmenting the repair with a cortical button has been shown to increase the load-to-failure better than the traditional 2-incision technique that employs transosseous fixation. Here we present our technique of 2-incision distal biceps repair with cortical button, a technique intended to maximize supination strength.

Inferior tilt of the glenoid leads to medialization and increases impingement on the scapular neck in reverse shoulder arthroplasty.

BACKGROUND: In reverse shoulder arthroplasty, Inferior tilt was originally promoted to decrease rates of baseplate failure. However, the literature is conflicting regarding the effect of tilt on scapular neck impingement, which has been associated with an increased risk of notching, increased risk of impingement-related instability, and decreased range of motion. We hypothesized that inferior tilt of -10° would lead to increased medialization and increased scapular neck impingement compared with 0° of tilt. METHODS: Twenty patients without glenoid bone loss undergoing reverse shoulder arthroplasty (RSA) at a single institution underwent computed tomography scans of the entire scapula and proximal humerus for preoperative planning. For each patient, we digitally implanted a 25-mm glenoid baseplate flush with the inferior rim of the glenoid. We then simulated impingement-free range of motion with 16 different implant configurations: glenoid tilt (0° vs. -10°), baseplate lateralization (0 mm vs. +6 mm), glenosphere size (36 mm vs. 42 mm), and neck-shaft angle (135° vs. 145°). The primary endpoint was external rotation with the arm at the side (ERS), which is the primary mode of both notching and impingement-related instability, and the secondary endpoint was adduction (ADD). We recorded the RSA angle, preoperative scapular neck length (SNL), and postoperative SNL. Data were compared by paired t tests and a multivariable regression analysis. RESULTS: In every simulation, inferior tilt led to more impingement on the scapular neck. Inferior tilt of the glenoid component was associated with a mean 27% decrease in impingement-free external rotation (P < .01 in all cases) and a mean 32% decrease in impingement-free ADD (P < .01 in all cases). Inferior tilt removed 3.2 mm of additional SNL (P < .001). Multivariable regression analysis showed that lateralization had the most impact on impingement-free external rotation and ADD (P < .001), followed by glenosphere size (P < .001), neck-shaft angle (P < .001), postoperative SNL (P < .001), glenoid tilt (P = .001), inclination (P < .001), and RSA angle (P = .023 for ERS and P = .025 for ADD). CONCLUSION: Relative to 0° of tilt of the baseplate, inferior tilt of -10° was associated with increased scapular neck impingement in ERS and ADD, likely a result of the increased medialization necessary to seat an inferiorly tilted implant, which shortens the scapular neck and brings the humerus closer to the scapula. This scapular neck impingement increases the risk of notching and impingement-related instability.

KAToB: Knotless All-Arthroscopic Intraarticular Tenodesis of the Biceps, An Efficient, Simple, Reproducible Technique.

Biceps tenodesis is a commonly performed procedure. It can be done using a multitude of fixation methods, at multiple locations, and either open or arthroscopic, with little if any clinical differences in the literature. Yet, many techniques have drawbacks in the risk of complications or in the technical ease. Here we present what we have found to be an efficient, simple, reproducible technique: KAToB, Knotless All-arthroscopic intraarticular Tenodesis of the Biceps using a knotless anchor at the articular margin. This technique minimizes the risk of nerve injury, infection, and fracture; has good clinical outcomes; and has a low rate of failure.

Triceps-Sparing Total Elbow Arthroplasty for Distal Humerus Fracture: The Lateral Paraolecranon Approach.

Distal humerus fractures in the elderly are a difficult problem to treat. Open reduction internal fixation has a high rate of complications, particularly because osteopenia compromises what is already tenuous fixation in a metaphyseal fracture. Total elbow arthroplasty is a more predictable outcome and easier recovery for these patients. However, most surgeons perform a low volume of total elbow arthroplasty. In addition, traditional exposure requires detachment of the triceps tendon. The lateral paraolecranon approach maintains the central tendon attachment to the olecranon while still facilitating relative ease of the procedure. Patients are allowed full active use of the triceps postoperatively, which is very helpful for polytrauma patients and those who are already dependent on assistive devices for ambulation.

The 2019 Arthroscopy Association of North America Traveling Fellowship-Los Gallos: New Friends on an Old Town Road.

We came in with high expectations, yet the Arthroscopy Association of North America (AANA) Traveling Fellowship far exceeded them. The 4 traveling fellows came from different backgrounds, different parts of North America, and different practice settings, including an independent private practice, a hybrid private-academic practice, the military, and academia. We were lucky to have been ushered along the way by our godfather, the distinguished John Richmond, M.D., Past-President of AANA and Associate Editor Emeritus of Arthroscopy, who was gracious enough to give his time to the expedition. Over the course of the journey, this gang came together quickly and forged relationships that will last a lifetime. We are extremely grateful to AANA for the privilege and will cherish the memories for years to come.

Managing the Endosteal Fibula During Arthroplasty for Proximal Humeral Fracture Sequelae.

Augmentation of proximal humeral fracture fixation with an endosteal fibular allograft has increased in popularity because it biomechanically improves construct stability and potentially may lead to a lower rate of humeral head collapse. However, the potential need for arthroplasty after proximal humeral fracture fixation may still arise. Placing a humeral stem in the presence of an existing intramedullary fibular graft is challenging because the fibula is dense cortical bone and is typically well-integrated by the time an arthroplasty would be performed. Some have proposed burring the proximal humerus open to receive a stem, or using cannulated intramedullary reamers until a humeral stem can be placed. These steps are tedious and inefficient. We have found the most efficient technique as treating the fibula as if it were a well-fixed humeral stem: freeing it up from the native bone and removing it in its entirety.

Comparison of radiographic and clinical outcomes of revision reverse total shoulder arthroplasty with structural versus nonstructural bone graft.

BACKGROUND: Revision shoulder arthroplasty in the setting of glenoid bone loss poses substantial surgical challenges. This study's purpose was to compare radiographic and clinical results of patients requiring structural iliac crest bone autograft (ICBA) for severe bone loss versus patients with less severe bone loss treated with nonstructural bone allograft (NSBA) in the setting of revision reverse total shoulder arthroplasty (RSA). METHODS: A retrospective cohort of 30 patients (70% of the 43 patients who met the inclusion criteria) undergoing revision RSA with ICBA (n = 15) or NSBA (n = 15) between 2007 and 2015 were analyzed at a minimum 2-year follow-up. Radiographic assessment included bone graft integration, bone graft resorption, glenosphere tilt, glenosphere version, and the presence of scapular notching. Clinical assessment included active range of motion, Penn Shoulder Score, Veterans RAND 12-item health survey, and need for revision surgery. RESULTS: No radiographic difference was found between the ICBA and NSBA groups with regard to implant position, graft integration, scapular notching, implant shift, or failure of fixation (P > .05). Of 15 patients with ICBA, 14 (93%) had at least partial integration of the bone graft. Some degree of resorption of the bone graft was noted in 6 of 15 patients (40%). There was no significant difference in postoperative active range of motion, Penn Shoulder Score, or Veterans RAND 12-item health survey score (P > .05 for all comparisons). One patient in the ICBA group underwent revision surgery for glenoid baseplate failure. CONCLUSION: Revision RSA with glenoid bone grafting resulted in good clinical and radiographic outcomes at short-term follow-up. Patients requiring structural ICBA were not at increased risk of component failure, radiographic or clinical complications, or inferior clinical outcomes.

Clinical and Radiographic Outcomes of a Posteriorly Augmented Glenoid Component in Anatomic Total Shoulder Arthroplasty for Primary Osteoarthritis with Posterior Glenoid Bone Loss.

BACKGROUND: The primary objectives of this study were to evaluate the ability of a posteriorly stepped augmented glenoid component, used in patients with primary glenohumeral osteoarthritis with B2 or B3 glenoid morphology, to correct preoperative retroversion and humeral head subluxation and to identify factors associated with radiographic radiolucency and patient-reported clinical outcomes. METHODS: We identified 71 shoulders with B2 or B3 glenoid morphology that underwent anatomic total shoulder arthroplasty with use of a posteriorly stepped augmented glenoid component and with a preoperative 3-dimensional computed tomography (3D-CT) scan and a minimum of 2 years of clinical and radiographic follow-up. The Penn Shoulder Score (PSS), shoulder range of motion, glenoid center-peg osteolysis, and postoperative version and humeral head subluxation were the main outcome variables of interest. RESULTS: Follow-up was a median of 2.4 years (range, 1.9 to 5.7 years); the mean patient age at treatment was 65 ± 7 years (range, 51 to 80 years). PSS, range of motion, humeral head centering, and glenoid version were significantly improved among all patients (p < 0.0001). Patients with persistent posterior subluxation of the humeral head postoperatively had worse preoperative fatty infiltration of the teres minor and greater postoperative component retroversion (p < 0.05). Patients with center-peg osteolysis had more preoperative joint-line medialization and posterior glenoid bone loss (p < 0.05). Patients with more preoperative humeral head posterior subluxation had a lower PSS, adjusting for confounders (p < 0.05). CONCLUSIONS: Posteriorly stepped augmented glenoid components can improve pathologic retroversion and posterior subluxation of the humeral head in B2 and B3 glenoids, with significant improvements found in clinical outcome scores at a minimum of 2 years of follow-up in the vast majority of patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Three-Dimensional Templating and Use of Standard Instrumentation in Primary Anatomic Total Shoulder Arthroplasty.

INTRODUCTION: Three-dimensional (3D) templating of the glenoid in anatomic shoulder arthroplasty allows for more accurate planning and more optimal positioning of the glenoid component than 2-dimensional computed tomography (2D CT) scans through an improved understanding of both the pathologic and the premorbid glenoid joint line, version, and inclination in reference to an idealized calculated glenoid position. STEP 1 OBTAIN A CT SCAN WITH 3D RECONSTRUCTION AND DEFINE GLENOID VERSION AND INCLINATION: Obtain a CT scan of the entire scapula and proximal part of the humerus with slices of ≤1 mm and a 3D reconstruction with subtraction of the humeral head, and identify the scapular and glenoid planes to define the pathologic version and inclination, which can be done in any commercially available software program while following these basic principles (Video 1). STEP 2 DEFINE PREMORBID GLENOID MORPHOLOGY: Carefully evaluate for the presence of the native glenoid, noting its version and inclination, and be careful to distinguish the true native glenoid from osteophytes (Video 2). STEP 3 PLACE THE VIRTUAL IMPLANT: Place the virtual glenoid component to restore the premorbid glenoid anatomy (Video 3). STEP 4 EVALUATE THE NEED FOR AN AUGMENTED GLENOID COMPONENT BONE GRAFT OR ECCENTRIC REAMING: In the presence of bone loss from posterior glenoid wear, assess the need for an augmented glenoid component, bone graft, or eccentric reaming to achieve adequate backside seating (Video 4). STEP 5 NOTE THE CENTER PIN POSITION AND TRAJECTORY: Once the glenoid component has been templated, note the starting location and trajectory of the center pin used for cannulated glenoid reaming and bone preparation (Video 5). STEP 6 REMOVE REMAINING CARTILAGE AND SOFT TISSUE FROM THE GLENOID SURFACE: Intraoperatively, remove remaining labrum and any remaining cartilage or soft tissue, and expose the glenoid periphery to clearly define the osseous anatomy, including the base of the coracoid, such that it mirrors what the 3D CT scan and preoperative plan display (Video 6). STEP 7 PLACE THE CENTER PIN ACCORDING TO THE PREOPERATIVE PLAN: Place the center pin for glenoid preparation in the previously templated location and trajectory to emulate the surgical plan defined in the software (Video 7). RESULTS: We performed a prospective, randomized controlled trial of positioning of the glenoid component in anatomic TSA using preoperative planning with 3D CT scans and standard instrumentation compared with using 3D CT preoperative planning with patient-specific instrumentation29.

High Complication Rate in Young Patients With High-Energy Intertrochanteric Femoral Fractures.

Although intertrochanteric femoral fractures in elderly patients are common injuries that have been studied extensively, little has been reported about high-energy intertrochanteric fractures in younger patients. This study examined the injury characteristics and outcomes of high-energy intertrochanteric fractures in patients younger than 65 years treated with either sliding hip screws (SHSs) or cephalomedullary nails (CMNs). A total of 37 patients younger than 65 years (mean age, 45 years) with high-energy intertrochanteric fractures and mean follow-up of 34 weeks were identified; 21 patients were treated with SHSs, and 16 patients were treated with CMNs. All fractures were AO/ Orthopaedic Trauma Association (OTA) fracture type 31A1 or 31A2. Injury characteristics, measures of surgical quality, treatment outcomes, and complications were compared. Despite high-energy mechanisms of injury, 84% of patients had AO/OTA type 31A1 fractures, 60% presented with an Injury Severity Score of 17 or higher, and 78% sustained other injuries. There were no significant differences in tip-apex distance (TAD), reduction quality, blood loss, or surgical time (P>.05) for fractures treated with SHSs or CMNs. The overall rate of major complications requiring revision surgery was 13.5%; this difference was not statistically significant (P=.36). Young patients with intertrochanteric fractures often have multisystem trauma; these fractures are difficult to reduce by closed means, and young patients are more prone to complications than older patients. In particular, varus collapse occurred at a high rate in young patients with intertrochanteric fractures treated with SHSs despite relatively simple fracture patterns, satisfactory TAD, and satisfactory reduction quality. [Orthopedics. 2017; 40(2):e293-e299.].