The Effect of Delayed Injection of Leukocyte-Rich Platelet-Rich Plasma Following Rotator Cuff Repair on Patient Function: A Randomized Double-Blind Controlled Trial.

PURPOSE: To investigate the effect of delayed application of leukocyte-rich platelet-rich plasma (PRP) on rotator cuff repair results as assessed by outcome scores and imaging at one year. METHODS: Patients with a symptomatic rotator cuff tear awaiting arthroscopic repair were approached to take part in the study. Final eligibility for the study was confirmed at the time of surgery. A total of 97 patients were randomized to an ultrasound guided injection of leukocyte-rich PRP or normal saline between 10 and 14 days postsurgery. A total of 87 patients completed clinical evaluation and underwent magnetic resonance imaging imaging at 1 year. Outcome scores included the American Shoulder and Elbow Score, Constant score, Western Ontario Rotator Cuff Index, and the Disabilities of the Arm, Shoulder and Hand Score. Structural integrity of the repair was assessed according to the Sugaya grading. Muscle fatty infiltration was assessed on magnetic resonance imaging using the Goutallier classification. RESULTS: At 1 year postsurgery, there was no significant difference between the treatment groups on any of the patient-reported outcome measures or Constant score. On postoperative imaging analysis, there was no difference in the retear rates (Sugaya 4 and 5) between the groups (21% in control group vs 15.3% in PRP group). Fatty infiltration on postoperative imaging was found to be significantly higher in the normal saline group compared with the PRP group (Kendall's tau-b P = .032). CONCLUSIONS: The delayed application of PRP postrotator cuff repair did not improve function as measured by patient-reported outcome measures and Constant score at 1 year postoperatively. LEVEL OF EVIDENCE: Level II, prospective randomized therapeutic trial.

A patient-derived Constant-Murley score is comparable to a clinician-derived score.

BACKGROUND: Although there are many advantages to patient-based assessment for musculoskeletal conditions, one common problem is that many of these assessments are perceived to be subjective. To overcome this limitation for patient-based shoulder evaluation, we developed a modified Constant-Murley score that allows patients to complete subjective and objective sections of the score. QUESTIONS/PURPOSES: The purpose of our study was to assess the reliability of the new patient-based Constant-Murley score questionnaire by comparing composite scores and subscores obtained with those obtained using the standard physician-based Constant-Murley questionnaire in the same group of patients. METHODS: Between August and October 2000, all patients having shoulder surgery in our institute were invited to participate in this study; 58 of 61 (95%) opted to do so and completed the patient-based questionnaire at preoperative and postoperative assessments. The clinician-based Constant-Murley score was performed by a clinician who was blinded to the corresponding patient-based questionnaire. Patients underwent various procedures ranging from manipulation under anesthesia and arthroscopic procedures to reverse shoulder arthroplasty. RESULTS: The mean patient-based and the clinician-based Constant-Murley scores were 47 (SD = 19.5; range, 4-90; N = 108) and 48 (SD = 19.9; range, 4-90; N = 108) points respectively. The mean difference was -1.3 (SD = 3; range, -11 to 8; N = 108) points. The new patient-based Constant-Murley score questionnaire reproduced the patient-based method and had substantial to almost perfect agreement with it for the composite score and various subgroups. CONCLUSIONS: These results suggest that a patient-based questionnaire can be used interchangeably with or in place of a clinician-based Constant-Murley score. These results apply to subjective and objective items of the Constant-Murley score.

Radiofrequency capsular shrinkage for voluntary shoulder instability.

We report a prospective study of 13 consecutive shoulders treated exclusively with radiofrequency capsular shrinkage for voluntary instability. Before surgery, voluntary instability had ceased in all patients with physiotherapy, but involuntary shoulder instability continued. The mean follow-up was 45 months (range, 32-57 months). According to the system of Rowe et al, the results were excellent in 3 shoulders (23.1%), fair in 1 (7.7%), and poor in 9 (69.2%). All 4 shoulders that had previous stabilization surgery had a recurrence of instability. Of the 6 shoulders with fair and poor Rowe ratings that had no previous stabilization surgery, 4 had a repeat capsular shrinkage. Two of these four shoulders had an excellent Rowe rating at final review. Overall, 5 of 9 patients (55.6%) with no previous surgery achieved stability by radiofrequency stabilization. In conclusion, results of radiofrequency capsular shrinkage in voluntary shoulder instability are poor. Results are improved with repeat capsular shrinkage. Radiofrequency capsular shrinkage is not recommended for patients who have had previous stabilization surgery.

Histologic evaluation of the glenohumeral joint capsule after radiofrequency capsular shrinkage for atraumatic instability.

We evaluated histologically 10 biopsy specimens taken preoperatively from the anterior-inferior glenohumeral ligament from patients with atraumatic instability who had undergone radiofrequency capsular shrinkage, 10 taken immediately postoperatively, and 13 taken before revision. The synovial and subsynovial layers returned to normal histology in biopsy specimens taken from 6 months onwards. Collagen bundles in the fibrous layer continued to have a reparative histology during the period of the study (up to 37 months). The type of radiofrequency probe used (monopolar or bipolar) had no effect on the histologic healing process (P > 0.5, chi2 test). A histologic score was introduced, and this was found to have an excellent intraobserver agreement (weighted kappa, 0.840) and a moderate interobserver agreement (weighted kappa, 0.698).

Arthroscopic management of the painful snapping scapula.

PURPOSE: The aim of this study was to evaluate the results of the arthroscopic management of the snapping scapula syndrome. TYPE OF STUDY: Case series. METHODS: Thirteen patients underwent surgery for painful scapular snapping that had not responded to adequate conservative treatment. They had no evidence of anatomic abnormalities on plain radiographs. All patients underwent bursectomy and resection of bands of fibrous tissue at the superomedial angle. Bone was resected from the superomedial angle only if it appeared to be prominent during arthroscopy. This occurred in 3 cases. The patients' outcomes were assessed subjectively by their ability to return to work and their return to leisure, as well as the Constant score. RESULTS: At the time of follow-up, 9 patients (69%) reported an improvement in their symptoms. Their median Constant score was 87 (range, 95 to 58). Four patients felt that their symptoms were unchanged or worse. Their median Constant score was 55 (range, 66 to 32). Of 9 employed patients, 8 returned to their previous careers. This group included 2 patients with physically demanding jobs. Of 9 patients who played sports regularly, 6 returned to their presymptomatic level of sporting activity. There were no complications. CONCLUSIONS: Subscapular bursectomy is a safe procedure with a low rate of morbidity. In the absence of a definable anatomic abnormality, arthroscopic bursectomy for the painful snapping scapula can result in satisfactory outcomes in approximately 70% of patients. More clearly defined indications for and contraindications against surgery are required to avoid poor results. Complete resolution of the snapping in the subscapular bursa is not necessary to obtain a satisfactory result. LEVEL OF EVIDENCE: Level IV, case series, no control group.

The vertical-apical suture Bankart lesion repair for anteroinferior glenohumeral instability.

We report the results of the vertical-apical suture Bankart lesion repair in 59 patients with traumatic anteroinferior glenohumeral instability. According to the system of Rowe et al, at a mean follow-up of 42 months (minimum, 2 years), 94.9% (56 patients) had a rating of good or excellent. Three patients had a recurrent dislocation due to further trauma. The mean Rowe score was 94.6, the mean Walch-Duplay score was 94.3, the mean Constant score was 90.4, and the mean rating on a numerical satisfaction scale was 8.7. The mean loss of external rotation with the arm at the side was 2.4 degrees, and in 90 degrees abduction it was 2.2 degrees. Of 44 patients, 35 (79.5%) returned to the same sport at the same level of activity, 7 returned to the same sport at a reduced level of activity, and 2 stopped all sporting activities. There were no complications. We recommend the vertical-apical suture as a technique for Bankart repair that uses absorbable sutures and no suture anchors or tacks.

Inferior capsular shift for multidirectional instability following failed laser-assisted capsular shrinkage.

This report is a prospective study of 10 consecutive patients treated by open inferior capsular shift following failed laser-assisted capsular shrinkage. Six patients had true multidirectional instability, 2 had anteroinferior instability with multidirectional laxity, and 2 had posteroinferior instability with multidirectional laxity. An anterior approach was used and a humeral-side capsular shift performed. The mean period of follow-up was 33 months (range, 18-47 months). On the basis of the Rowe system,9 patients had excellent results and 1 had a poor result at final follow-up. The mean score improved from 37.5 to 94 points on the Rowe scale, from 73 to 90.4 points on the Constant scale, and from 1.6 to 7.7 points on a numeric satisfaction scale (P <.001 for all). The one poor result was in the only patient who underwent multiple attempts at open stabilization prior to laser-assisted capsular shrinkage. There were no complications. We conclude that the results of an inferior capsular shift for multidirectional instability are not necessarily adversely affected by a previous failed laser-assisted capsular shrinkage procedure.

Operative management of the frozen shoulder in patients with diabetes.

Forty-three patients with diabetes (47 shoulders) who had a manipulation under anesthesia only (24 shoulders), a manipulation under anesthesia followed by an arthroscopy (12 shoulders), or an arthroscopic release (11 shoulders) for a frozen shoulder were followed-up for a mean period of 35 months. The mean Constant score improved from 20.3 to 63.7 points (P <.001). The mean improvement in forward flexion was 71.7 degrees, in abduction 78.5 degrees, in external rotation with the arm at the side 36.3 degrees, and in internal rotation from the buttock to the first lumbar vertebra (P <.001 for all). When gentle manipulation with the patient under anesthesia was possible, the outcome was satisfactory in 13 of 15 shoulders (86.7%) in patients with non-insulin-dependent diabetes and in 17 of 21 shoulders (81%) in patients with insulin-dependent diabetes (P >.5). Insulin-dependent patients with diabetes were more likely to require an arthroscopic release than patients with non-insulin-dependent diabetes (P <.05). Most of our patients obtained their maximum relief of pain and functional recovery within 3 months of surgery. We recommend manipulation under anesthesia for the resistant frozen shoulder in patients with diabetes. Arthroscopic release is required when mobilization under anesthesia is not possible.