Liposomal Bupivacaine vs Interscalene Nerve Block for Pain Control After Shoulder Arthroplasty: A Retrospective Cohort Analysis.

The aim of this study was to compare liposomal bupivacaine and interscalene nerve block (ISNB) for analgesia after shoulder arthroplasty. We compared 37 patients who received liposomal bupivacaine vs 21 who received ISNB after shoulder arthroplasty by length of hospital stay (LOS), opioid consumption, and postoperative pain. Pain was the same in both groups for time intervals of 1 hour and 8 to 14 hours postoperatively. Compared with ISNB patients, liposomal bupivacaine patients reported less pain at 18 to 24 hours (P = .001) and 27 to 36 hours (P = .029) and had lower opioid consumption on postoperative days 2 (P = .001) and 3 (P = .002). Mean LOS for liposomal bupivacaine patients was 46 ± 20 hours vs 57 ± 14 hours for ISNB patients (P = .012). Sixteen of 37 liposomal bupivacaine patients vs 2 of 21 ISNB patients were discharged on the first postoperative day (P = .010). Liposomal bupivacaine was associated with less pain, less opioid consumption, and shorter hospital stays after shoulder arthroplasty compared with ISNB.

Prosthetic design of reverse shoulder arthroplasty contributes to scapular notching and instability.

AIM: To evaluate whether implant design, glenoid positioning, and other factors influenced instability and scapular notching in reverse total shoulder arthroplasty. METHODS: We retrospectively reviewed records of patients who had undergone reverse total shoulder arthroplasty by the senior author from July 2004 through October 2011 and who had at least 24 mo of follow-up. The 58 patients who met the criteria had 65 arthroplasties: 18 with a Grammont-type prosthesis (Grammont group) and 47 with a lateral-based prosthesis (lateral-design group). We compared the groups by rates of scapular notching and instability and by radiographic markers of glenoid position and tilt. We also compared glenoid sphere sizes and the number of subscapularis tendon repairs between the groups. Rates were compared using the Fisher exact test. Notching severity distribution was compared using the χ2 test of association. Significance was set at P < 0.05. RESULTS: The Grammont group had a higher incidence of scapular notching (13 of 18; 72%) than the lateral-design group (11 of 47; 23%) (P < 0.001) and a higher incidence of instability (3 of 18; 17%) than the lateral-design group (0 of 47; 0%) (P = 0.019). Glenoid position, glenoid sphere size, and subscapularis tendon repair were not predictive of scapular notching or instability, independent of implant design. With the lateral-based prosthesis, each degree of inferior tilt of the baseplate was associated with a 7.3% reduction in the odds of developing notching (odds ratio 0.937, 95%CI: 0.894-0.983). CONCLUSION: The lateral-based prosthesis was associated with less instability and notching compared with the Grammont-type prosthesis. Prosthesis design appears to be more important than glenoid positioning.

Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff.

BACKGROUND: Treating shoulders with osteoarthritis, an intact rotator cuff, and substantial glenoid bone loss is challenging. One option is reaming the glenoid flat and inserting a reverse prosthesis. This study reports the subjective, objective, and radiographic results of reverse total shoulder arthroplasty (RTSA) in this population. METHODS: We retrospectively reviewed 42 consecutive patients (23 women; mean age, 71 years [range, 53 to 89 years]) with primary glenohumeral osteoarthritis, intact rotator cuffs, and Walch type-A2 (n = 19), B2 (n = 5), or C glenoids (n = 18) who had undergone a total of 42 RTSAs with glenoid reaming without bone-grafting between 2008 and 2013 (mean follow-up, 36 months [range, 24 to 66 months]). All patients were evaluated before and after surgery subjectively (using a visual analog scale for pain and 5 shoulder-specific outcome instruments), objectively (with goniometric examination of shoulder range of motion), and radiographically (to assess baseplate loosening and degree of scapular notching). RESULTS: One baseplate (2%) failed, requiring revision surgery. There were no other signs of baseplate loosening in any patient at the last follow-up. Preoperatively to postoperatively, pain improved significantly (p < 0.001), as did all patient-reported outcome measures and the following range-of-motion parameters (p ≤ 0.001): active abduction, active flexion, and active external rotation with the arm elevated 90°. Eight (19%) of the patients had notching. CONCLUSIONS: RTSA without bone-grafting and with medialization of the baseplate in patients with osteoarthritis and severe glenoid bone loss resulted in significant improvement in pain and function with reliable short-term implant survivorship and may be a good alternative to anatomical TSA. Longer follow-up is needed to determine the relative advantages and disadvantages. This was an "off-label" indication for this device. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Autologous distal clavicle versus autologous coracoid bone grafts for restoration of anterior-inferior glenoid bone loss: a biomechanical comparison.

BACKGROUND: Treating anterior glenoid bone loss in patients with recurrent shoulder instability is challenging. Coracoid transfer techniques are associated with neurologic complications and neuroanatomic alterations. The purpose of our study was to compare the contact area and pressures of a distal clavicle autograft with a coracoid bone graft for the restoration of anterior glenoid bone loss. We hypothesized that a distal clavicle autograft would be as effective as a coracoid graft. METHODS: In 13 fresh-frozen cadaveric shoulder specimens, we harvested the distal 1.0 cm of each clavicle and the coracoid bone resection required for a Latarjet procedure. A compressive load of 440 N was applied across the glenohumeral joint at 30° and 60° of abduction, as well as 60° of abduction with 90° of external rotation. Pressure-sensitive film was used to determine normal glenohumeral contact area and pressures. In each specimen, we created a vertical, 25% anterior bone defect, reconstructed with distal clavicle (articular surface and undersurface) and coracoid bone grafts, and determined the glenohumeral contact area and pressures. We used analysis of variance for group comparisons and a Tukey post hoc test for individual comparisons (with P <.05 indicating a significant difference). RESULTS: The articular distal clavicle bone graft provided the lowest mean pressure in all testing positions. The coracoid bone graft provided the greatest contact area in all humeral positions, but the difference was not significant. CONCLUSION: An articular distal clavicle bone graft is comparable in glenohumeral contact area and pressures to an optimally placed coracoid bone graft for restoring glenoid bone loss. LEVEL OF EVIDENCE: Basic Science Study; Biomechanics.

Does preoperative American Society of Anesthesiologists score relate to complications after total shoulder arthroplasty?

BACKGROUND: For hip and knee arthroplasties, an American Society of Anesthesiologists (ASA) score greater than 2 is associated with an increased risk of medical and surgical complications. No study, to our knowledge, has evaluated this relationship for total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (reverse TSA). QUESTIONS/PURPOSES: We aimed to assess the relationship between the ASA score and (1) surgical complications, (2) medical complications, and (3) hospitalization length after TSA, reverse TSA, and revision arthroplasty. METHODS: We retrospectively analyzed all patients who had undergone TSAs, reverse TSAs, or revision arthroplasties by the senior author (EGM) from November 1999 through July 2011 who had at least 6 months' followup. Of the 485 procedures, 452 (93.2%) met the inclusion criteria. Data were collected on patient demographics, comorbidities, hospitalization length, and short-term (≤ 6 months) medical and surgical complications. Logistic regression analysis modeled the risk of having postoperative complications develop as a function of the ASA score. RESULTS: Patients with an ASA score greater than 2 had a greater risk of having a surgical complication develop (p < 0.001; OR, 2.27; 95% CI, 1.36-3.70) and three times the risk of prosthesis failure (ie, component dislocation, component loosening, and hardware failure) (p < 0.001; OR, 3.23; 95% CI, 1.54-6.67). Higher ASA scores were associated with prolonged length of hospitalization (effect size 0.46, p < 0.001), but not medical complications. CONCLUSIONS: ASA score is associated with surgical, but not medical, complications after TSA and reverse TSA. The ASA score could be used for risk assessment and preoperative counseling. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Impingement is not impingement: the case for calling it "Rotator Cuff Disease".

Historically, many causes have been proposed for rotator cuff conditions. The most prevalent theory is that the rotator cuff tendons, especially the supraspinatus, make contact with the acromion and coracoacromial ligament, resulting in pain and eventual tearing of the tendon. However, more recent evidence suggests that this concept does not explain the changes in rotator cuff tendons with age. The role of acromioplasty and coracoacromial ligament release in the treatment of rotator cuff disease has become questioned. Evidence now suggests that tendinopathy associated with aging may be a predominant factor in the development of rotator cuff degeneration. We propose that the overwhelming evidence favors factors other than "impingement" as the major cause of rotator cuff disease and that a paradigm shift in the way the development of rotator cuff pathology is conceptualized allows for a more comprehensive approach to the care of the patient with rotator cuff disease.

Postoperative death associated with a reverse prosthesis.

The mortality rate after total shoulder arthroplasty, and specifically after reverse total shoulder arthroplasty, has not received much attention in the literature. Although complications of the reverse total shoulder arthroplasty are well known, fatalities secondary to complications related to the unique features of the reverse prosthesis have not, to our knowledge, been previously reported. We report the case of an elderly man who developed shoulder instability after the implantation of a reverse prosthesis followed by disassociation of the glenosphere from the baseplate. After a reoperation to revise and reassemble the components, he developed an infected shoulder and sepsis, and subsequently died from the complications of sepsis. This death represents a perioperative mortality rate of 0.5% in our series of 190 cases. The mortality rate after reverse total shoulder seems to be similar to that after standard total shoulder arthroplasty.

The Latarjet coracoid process transfer procedure: alterations in the neurovascular structures.

BACKGROUND: The Latarjet coracoid process transfer procedure is an established, reliable treatment for glenoid deficiency associated with recurrent anterior shoulder instability, but changes in neurovascular anatomy resulting from the procedure are a concern. The purpose of our cadaveric study was to identify changes in the neurovascular anatomy after a Latarjet procedure. MATERIALS AND METHODS: We obtained 4 paired, fresh-frozen cadaveric forequarters (8 shoulders) from the Maryland State Anatomy Board. In each shoulder, we preoperatively measured the distances from the midanterior glenoid rim to the musculocutaneous nerve, axillary nerve, and axillary artery in 2 directions (lateral to medial and superior to inferior) and with the arm in 2 positions (0° abduction/neutral rotation; 30° abduction/30° external rotation), for a total of 12 measurements. We then created a standardized bony defect in the anterior-inferior glenoid, reconstructed it with the Latarjet procedure, and repeated the same measurements. Two examiners independently took each measurement twice. Inter-rater reliability was adequate, allowing pre-Latarjet measurements to be combined, averaged, and compared with combined and averaged post-Latarjet measurements by using paired Student t tests (significance, P ≤ .05). RESULTS: We found (1) significant differences in the location of the musculocutaneous nerve in the superior-to-inferior direction for both arm positions, (2) notably lax and consistently overlapping musculocutaneous and axillary nerves, and (3) an unchanged axillary artery location. CONCLUSIONS: The Latarjet procedure resulted in consistent and clinically significant alterations in the anatomic relationships of the musculocutaneous and axillary nerves, which may make them vulnerable to injury during revision surgery.

Intraarticular abnormalities in overhead athletes are variable.

BACKGROUND: The cause of shoulder pain and dysfunction in the overhead athlete can be variable. Several studies illustrate the wide variety of lesions seen at the time of arthroscopy in overhead athletes who require surgery but it is unclear whether these differ by sport. QUESTIONS/PURPOSES: We examined overhead athletes with shoulder dysfunction to determine (1) the range of arthroscopically visualized shoulder abnormalities with specific attention to the posterosuperior glenohumeral joint and the rotator cuff; and (2) the relationship of sport type to these abnormalities. METHODS: We reviewed our institution's database for professional and collegiate athletes in overhead sports who, from 1996 through 2010, had diagnostic shoulder arthroscopy for insidious, nontraumatic, persistent pain and inability to participate in their sport. A descriptive analysis of the arthroscopic findings from 51 consecutive patients (33 males, 18 females; mean age, 25 years; range, 15-59 years) was done. We analyzed the arthroscopic findings with respect to sport using analysis of variance and Fisher's exact test. RESULTS: There was a wide range of superior labrum, posterosuperior glenoid, and rotator cuff abnormalities. Overall, the most frequent abnormalities were posterosuperior glenohumeral joint changes. Swimmers had fewer intraarticular abnormalities than baseball players. CONCLUSIONS: We found a wide spectrum of intraarticular abnormalities in the shoulder of overhead athletes with shoulder pain requiring surgery. Additional study is needed to determine whether these abnormalities or combinations relate to specific athletic movements. LEVEL OF EVIDENCE: Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

Triceps tendons: a biomechanical comparison of intact and repaired strength.

HYPOTHESIS: Our hypothesis was that the autograft-augmented direct repair of torn triceps tendons would have strength superior than that of direct repair when compared to the strength of intact distal triceps tendons. MATERIALS AND METHODS: The strength of the intact distal triceps tendon in 8 unpaired, fresh frozen cadaver specimens was measured to tendon failure by uniaxial tension in the sagittal plane. The torn triceps tendons were then repaired by direct repair (sutures through drill holes) or an autograft-augmented direct repair. Each tendon repair was biomechanically tested to failure, and load to displacement curves and the site of tendon failure were recorded. Tendon strength after each repair was compared with that of the other repair technique and with that of the intact triceps tendon. Significance was set at P < .05. RESULTS: Average failure loads for intact, direct repair, and augmented repair tendons were 1741, 317, and 593 N, respectively; augmented repairs were significantly stronger than direct repairs. In the intact tendon, failure occurred at the insertion site through a tear at the bone tendon interface or through a small cortical avulsion. In the repaired tendons, all but 1 failure occurred through the suture; 1 augmented repair failed first at the tendon and then through the suture. DISCUSSION: There is a paucity of clinical data regarding the optimal repair for distal triceps avulsion. We found that triceps repair affords less strength than the intact tendon, but augmented repair was nearly twice as strong as that of direct repair. Augmented repair may allow earlier range of motion, weightbearing, and rehabilitation, theoretically decreasing complications associated with the procedure. CONCLUSIONS: Augmented triceps repair is superior to direct triceps repair for a distal triceps avulsion produced in a cadaver model.

The timing of rotator cuff repair for the restoration of function.

INTRODUCTION: This study was developed to test the hypothesis that there is a period in which a painful, traumatic rotator cuff tear, with associated weakness and the inability to abduct above shoulder level, should be repaired to allow for improvement in function. METHODS: Forty-two consecutive, prospectively followed patients met the criteria for entrance into this study. Of those, 36 patients were available for a minimum 9 months follow-up (average, 31 months; range, 9-71) by office visit. Patient outcomes were measured using the UCLA End-Result and ASES scoring systems. Patient variables, including time from injury to repair, tear size, degree of preoperative fat infiltration, patient satisfaction, and improvement in pain, were evaluated for their association with surgical outcome using independent t testing. Time to repair was evaluated at 0-2 months, 2-4 months, and greater than 4 months. RESULTS: Pain scores improved from 7 to 1.4 (P < .01) and active elevation improved from 55° to 133° (P < .01). UCLA/ASES scores improved from 8/30 to 26/79, respectively (P < .01, P < .01). All but 2 of the 36 patients were satisfied with their result. Preoperative fatty atrophy did not correlate with postoperative function. Rotator cuff tear size had no influence on patient outcome if repaired before 4 months. Massive tears repaired after 4 months had the worst outcome. CONCLUSION: Our results emphasize that the treatment outcome for traumatic rotator cuff tears of all sizes, with associated weakness, is not compromised up to 4 months after their injury.

Does a positive neer impingement sign reflect rotator cuff contact with the acromion?

BACKGROUND: One possible cause of shoulder pain is rotator cuff contact with the superior glenoid (cuff-glenoid contact) with the arm in flexion, as occurs during a Neer impingement sign. It has been assumed that the pain with a Neer impingement sign on physical examination of the shoulder was secondary to the rotator cuff making contact with the anterior and lateral acromion. QUESTIONS/PURPOSES: We determined if the arm position where pain occurs with a Neer impingement sign would correlate with the position where the rotator cuff made contact with the superior glenoid, as determined by arthroscopic evaluation. PATIENTS AND METHODS: We prospectively studied 398 consecutive patients with a positive Neer impingement sign during office examination and used a handheld goniometer to measure (in degrees of flexion) the arm position in which impingement pain occurred. During subsequent arthroscopy, the arm was moved into a similar position, and we measured the arm's position in flexion at the point the rotator cuff made contact with the superior glenoid using a handheld goniometer. We compared the degrees of flexion at which pain occurred preoperatively and at which there was cuff-glenoid contact. RESULTS: Among the 398 patients, 302 (76%) had arthroscopically documented cuff-glenoid contact, whereas 96 did not. For the 302 patients with a positive Neer sign preoperatively and with arthroscopically documented cuff-glenoid contact, the average preoperative impingement pain position was 120.1°±26.7°, similar to that of the average intraoperative cuff-glenoid contact position of 120.6°±14.7°. CONCLUSIONS: Our data suggest pain associated with a positive Neer sign more often relates to contact of the rotator cuff with the superior glenoid than to contact between the rotator cuff and acromion. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Techniques for suture anchor removal in shoulder surgery.

Although suture anchor complications after arthroscopic shoulder surgery are uncommon, they can be devastating, such as articular cartilage or bone loss secondary to a dislodged or prominent suture anchor. Proper insertion of the anchor is the most important factor in the prevention of this complication, but if a complication occurs, prompt recognition and treatment are important to prevent damage to the shoulder. The goals were to (1) discuss strategies for preventing or dealing with dislodged or prominent suture anchors and (2) introduce techniques for removal of these implants.

Clinical and diagnostic tests for shoulder disorders: a critical review.

The shoulder is one of the most complex joints in the human body and, as such, presents an evaluation and diagnostic challenge. The first steps in its evaluation are obtaining an accurate history and physical examination and evaluating conventional radiography. The use of other imaging modalities (eg, ultrasound, magnetic resonance imaging and computed tomography) should be based on the type of additional information needed. The goals of this study were to review the current limitations of evidence-based medicine with regard to shoulder examination and to assess the rationale for and against the use of diagnostic physical examination tests.

An analysis of shoulder laxity in patients undergoing shoulder surgery.

BACKGROUND: It has been recognized that there is a distinction between shoulder laxity and shoulder instability and that there is a wide range of normal shoulder laxities. Our goals were (1) to evaluate if the ability to subluxate the shoulder over the glenoid rim in patients under anesthesia would be more prevalent than the inability to do so, (2) to determine if patients with a diagnosis of instability would have significantly more shoulder laxity in the operatively treated shoulder than in the contralateral shoulder, and (3) to evaluate the observation that higher grades of shoulder laxity would be related to a diagnosis of shoulder instability. We hypothesized that, on examination with the patient under anesthesia, most shoulders could be subluxated over the glenoid rim and that the degree of shoulder laxity would be related to diagnosis. METHODS: In the present study of 1206 patients undergoing shoulder surgery, we evaluated the symptomatic and contralateral shoulders with use of a modified anterior and posterior drawer test and a sulcus sign test, with the patients under anesthesia. The anterior and posterior translations were graded as no subluxation (Grade I), subluxation over the glenoid rim with spontaneous reduction (Grade II), or subluxation without spontaneous reduction (Grade III). The sulcus sign was graded as <1.0 cm (Grade I), 1.0 to 2.0 cm (Grade II), or >2.0 cm (Grade III). RESULTS: When the patients were evaluated while under anesthesia, the humeral head could be subluxated over the rim anteriorly in 81.6% (984 of 1206) of the patients and posteriorly in 57.5% (693 of 1206) of the patients. When the patients were evaluated while under anesthesia, there was an increase in the laxity grade anteriorly, posteriorly, and inferiorly in 50.8%, 36.3%, and 15.8% of the patients, respectively, as compared with the preoperative assessment. For all laxity testing, the higher the grade of laxity in an anterior, posterior, or inferior direction, the greater the chance that the patient had a diagnosis of instability. Compared with Grade-I laxity, Grade-III laxity increased the odds of a diagnosis of instability in the anterior (odds ratio, 170), posterior (odds ratio, 32), and inferior (odds ratio, 10.3) directions. Compared with Grade-I laxity, Grade-II laxity increased the odds of a diagnosis of instability in the anterior (odds ratio, 9.8), posterior (odds ratio, 4.6), and inferior (odds ratio, 4.4) directions. CONCLUSIONS: The ability to subluxate the humeral head over the glenoid rim in the patient who is undergoing shoulder surgery under anesthesia is common regardless of the diagnosis. Higher grades of shoulder laxity are associated with shoulder instability.

Clinical and imaging assessment for superior labrum anterior and posterior lesions.

In the evaluation of the painful shoulder, especially in the overhead athlete, diagnosing superior labrum anterior and posterior (SLAP) lesions continues to challenge the clinician because of 1) the lack of specificity of examination tests for SLAP; 2) a paucity of well-controlled studies of those tests; and 3) the presence of coexisting confounding abnormalities. Some evidence indicates that multiple positive tests increase the likelihood that a SLAP lesion is present, but no one physical examination finding conclusively makes that diagnosis. The goals of this article were to review the physical examination techniques for making the diagnosis of SLAP lesions, to evaluate the clinical usefulness of those examinations, and to review the role of magnetic resonance imaging in making the diagnosis.