Analysis of reasons for failure to return to sport after Latarjet surgery: a systematic review.

BACKGROUND: The purpose of this study was to perform a systematic review of the literature to identify Shoulder Instability Return to Sport after Injury (SIRSI) scores in athletes who underwent open Latarjet surgery, determine the reasons why athletes failed to return to play (RTP) after Latarjet surgery, and compare SIRSI scores of those who did vs. did not RTP. METHODS: According to PRISMA guidelines, the PubMed, SportDiscus, and Ovid MEDLINE databases were queried to identify studies evaluating return to sport after Latarjet surgery. Study quality was assessed using the MINORS criteria. Studies were included if RTP after Latarjet surgery and a psychological factor were evaluated, with potential psychological factors including readiness to RTP and reasons for failure to RTP. RESULTS: Fourteen studies, 10 of level III evidence and 4 of level IV evidence, with 1034 patients were included. A total of 978 athletes were eligible to RTP. Of these, 792 (79%) successfully returned to play and 447 (56.4%) returned to play at their previous level of play. Mean RTP time was 6.2 months. Postoperative SIRSI scores averaged 71.2 ± 8.8 at a mean of 21 months' follow-up. Postoperative SIRSI scores for those able to RTP was 73.2, whereas athletes unable to RTP scored an average of 41.5. Mean postoperative SIRSI scores for those in contact sports was 71.4, whereas those in noncontact sports was 86.5. There were 31 athletes with a documented reason why they did not RTP, with postoperative shoulder injury being the most common reason (54.5%). Fear of reinjury and feeling "not psychologically confident" each represented 6.5% of the total. CONCLUSION: Athletes who RTP have higher average SIRSI scores than those who are unable to RTP. Of the athletes who documented why they did not RTP, more than half cited a shoulder injury as their reason for not returning to play, whereas fear of reinjury and lack of psychological readiness were other common reasons.

High Rate of Return to Sporting Activity Among Overhead Athletes With Subpectoral Biceps Tenodesis for Type II SLAP Tear.

PURPOSE: To evaluate the functional and athletic outcomes after primary subpectoral biceps tenodesis for type II SLAP tear in overhead athletes. METHODS: All competitive elite athletes with type II SLAP tears undergoing biceps tenodesis by a single surgeon were isolated between 2007 and 2015. Exclusion criteria were applied to individuals not involved in overhead athletics, clinical follow-up <24 months, adjacent rotator cuff or labral repair, concomitant SLAP repair, and/or previous arthroscopic shoulder surgery. Patient-reported outcome measures included visual analog scale (VAS), Kerlan Jobe Orthopaedic Clinic shoulder score, and Single Assessment Numerical Assessment. Clinical and sporting outcomes were recorded using a sports-specific questionnaire. RESULTS: Of 22 identified patients, 16 competitive overhead athletes (72.7%; 11 men, 5 women) with a mean age of 21.0 years were available at mean 4.5-year follow-up. Baseball or softball comprised the majority of patients (n = 9; 56.3%), followed by gymnastics (n = 2), swimming (n = 2), and other sports (n = 3). At mean 4.1 months postoperatively, 13 patients (81.3%) returned to previous level of athletic activity, whereas 2 patients (12.5%) failed to return to sporting activity and 1 (6.3%) returned at a lower level of competition. VAS pain significantly decreased from an average of 4.4 preoperatively to 1.7 postoperatively (P = .002), and mean Single Assessment Numerical Assessment scores also demonstrated significant improvement (55.4-76.7; P = .008). Final mean Kerlan Jobe Orthopaedic Clinic score was 74.0 (standard deviation 25.9), including 2 patients with suboptimal outcomes due to persistent pain. There were no significant differences in mean forward flexion or rotation in either the adducted or throwing position (P > .05), although small, significant decreases in postoperative active abduction were noted (165° vs 155°; P = .003). CONCLUSIONS: In the current series of competitive overhead athletes, 81% of patients returned to previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear. Athletes reliably experienced significant decreased activity-related pain with athletic function. LEVEL OF EVIDENCE: IV, case series.

How does depressive disorder impact outcomes in patients with glenohumeral osteoarthritis undergoing primary reverse shoulder arthroplasty?

BACKGROUND: Current literature shows that the prevalence of depressive disorders (DD) is increasing in the United States. Patients with DD have worse outcomes after shoulder arthroplasty; however, properly defined inclusion and exclusion criteria evaluating the effects of DD on primary reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare the outcomes of patients with and without DD undergoing primary RSA, evaluating: (1) in-hospital length of stay (LOS), (2) medical complications, (3) emergency department (ED) utilizations, and (4) cost of care. METHODS: A retrospective query was performed using a nationwide administrative claims database from 2010 to 2020 for all patients who underwent primary RSA for the treatment of glenohumeral osteoarthritis. The query yielded a total of 24,326 patients within the study (DD, n = 4084) and comparison (without DD, n = 20,242) cohorts. The primary end points were in-hospital LOS, 90-day medical complications, and total 90-day episode of care costs. Subanalyses compared whether DD diagnosis and preoperative ED utilization within 6 months of RSA were associated with increased incidence and odds of postoperative ED utilization within 90 days. P values less than .004 were considered statistically significant. RESULTS: Patients with DD undergoing primary RSA had significantly longer LOS (3 vs. 2 days, P < .0001) compared with patients without DD. The study group also had higher frequency and odds ratio (OR) of complications (47.40% vs. 17.63%; OR: 2.27, P < .0001) such as pneumonia (10.04% vs. 2.15%; OR: 2.88, 95% confidence interval [CI]: 2.47-3.35, P < .0001), cerebrovascular accidents (3.13% vs. 0.86%; OR: 2.69, 95% CI: 2.09-3.46, P < .0001), myocardial infarctions (1.98% vs. 0.51%; OR: 2.54, 95% CI: 1.84-3.50, P < .0001), and other adverse events. Among patients who had a diagnosis of DD, preoperative ED utilization within 6 months of RSA was associated with increased odds of postoperative ED utilization within 90 days compared with those without ED utilization preoperatively (15.08% vs. 13.64%; OR: 1.16, 95% CI: 1.04-1.28, P = .003). Controlling for preoperative ED utilization and comorbidities, patients with DD experienced a 2- to 3-fold increase in postoperative ED use within 90 days after surgery (P < .0001). Patients with DD also incurred significantly higher episode of care costs ($19,363.10 vs. $17,927.55, P < .0001). CONCLUSION: This retrospective study shows that patients with DD undergoing primary RSA for the treatment of glenohumeral osteoarthritis have longer in-hospital LOS, higher rates of complications, and increased costs of care. Preoperative health care utilization among patients with DD may be associated with increased utilization postoperatively.

Long-term outcomes after osteochondral allograft transplantation to the humeral head.

BACKGROUND: Long-term outcomes of osteochondral allograft (OCA) transplantation to the humeral head have been sparsely reported in the literature. PURPOSE: To evaluate outcomes and survivorship of OCA transplantation to the humeral head in patients with osteochondral defects at a minimum of 10 years of follow-up. METHODS: A registry of patients who underwent humeral head OCA transplantation between 2004 and 2012 was reviewed. Patients completed pre and postoperative surveys including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, Short Form 12 (SF-12), and the visual analog scale. Failure was defined by conversion to shoulder arthroplasty. RESULTS: Fifteen of 21 (71%) patients with a minimum of ten year of follow-up (mean: 14.2 ± 2.40) were identified. Mean patient age was 26.1 ± 8.8 years at the time of transplantation and eight (53%) patients were male. Surgery was performed on the dominant shoulder in 11 of the 15 (73%) cases. The use of local anesthetic delivered via an intra-articular pain pump was the most often reported underlying etiology of chondral injury (n = 9; 60%). Eight (53%) patients were treated with an allograft plug, while seven (47%) patients were treated with a mushroom cap allograft. At final follow-up, mean American Shoulder and Elbow Surgeons (49.9 to 81.1; P = .048) and Simple Shoulder Test (43.1 to 83.3; P = .010) significantly improved compared to baseline. Changes in mean SF-12 physical (41.4 to 48.1; P = .354), SF-12 mental (57.5 to 51.8; P = .354), and visual analog scale (4.0 to 2.8; P = .618) did not reach statistical significance. Eight (53%) patients required conversion to shoulder arthroplasty at an average of 4.8 ± 4.7 years (range: 0.6-13.2). Kaplan-Meier graft survival probabilities were 60% at 10 years and 41% at 15 years. CONCLUSION: OCA transplantation to the humeral head can result in acceptable long-term function for patients with osteochondral defects. While patient-reported outcomes metrics were generally improved compared to baseline, OCA graft survival probabilities diminished with time. The findings from this study can be used to counsel future patients with significant glenohumeral cartilage injuries and set expectations about the potential for further surgery.

High Rate of Return to Work by 3 Months Following Latarjet for Anterior Shoulder Instability.

PURPOSE: To evaluate the rate and duration of return to work in patients undergoing Latarjet for failed soft-tissue stabilization or glenoid bone loss. METHODS: Consecutive patients undergoing Latarjet from 2005 to 2015 at our institution were retrospectively reviewed at a minimum of 2 years postoperatively. Patients completed a standardized and validated work questionnaire, Western Ontario Shoulder Instability Index Survey, and a satisfaction survey. RESULTS: Of 89 eligible patients who had Latarjet, 67 patients (75.3%) responded to the questionnaire, of whom 51 patients (76.1%) were employed within 3 years before surgery (mean age: 29.9 ± 11.8 years; mean follow-up: 54.6 ± 11.9 months) and had an average glenoid bone loss of 14.5 ± 6.1%. Fifty patients (98.0%) returned to work by 2.7 ± 3.0 months postoperatively; 45 patients (88.2%) patients returned to the same level of occupational intensity. Those who held sedentary, light, moderate, or heavy intensity occupations returned to their previous occupation at a rate of 100.0%, 93.3%, 90.0%, and 66.7% (P = .2) at a duration of 1.2 ± 1.6 months, 1.8 ± 1.9 months, 3.1 ± 3.5 months, and 6.5 ± 4.1 months (P = .001), respectively. The average postoperative Western Ontario Shoulder Instability Index score was 70.9 ± 34.2. Fifty patients (98.0%) noted at least "a little improvement" in their quality of life following surgery, with 35 patients (68.6%) noting great improvement. Furthermore, 49 patients (96.1%) reported being satisfied with their procedure, with 25 patients (49.0%) reporting being very satisfied. Four patients (7.8%) returned to the operating room, with 1 patient (2.0%) requiring arthroscopic shoulder stabilization. CONCLUSIONS: Approximately 98% of patients who underwent Latarjet returned to work by 2.7 ± 3.0 months postoperatively. Patients with greater-intensity occupations had a longer duration of absence before returning to their preoperative level of occupational intensity. Information regarding return to work is imperative in preoperative patient consultation to manage expectations. LEVEL OF EVIDENCE: IV, case series.

Biomechanical comparison of novel ulnar collateral ligament reconstruction with internal brace augmentation vs. modified docking technique.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) is a common surgery among baseball pitchers. UCL repair combined with augmentation using high-strength tape, referred to as an internal brace, was developed as an alternative to UCLR in select patients with the benefit of allowing these athletes to return to sport (RTS) faster. A combined UCLR with an internal brace may allow players indicated for a UCLR to RTS more expeditiously. METHODS: Twenty-four cadaveric elbows were divided into 3 groups: 12 specimens into the modified docking (MD) group, 6 into the double-docking (DD) group, and 6 into the double docking with internal brace augmentation (DDA) group. This allowed a 1:1 comparison of the MD to the DD and the MD to the DDA. Valgus cyclic testing of native and reconstructed specimens was executed at 90° elbow flexion. After preconditioning, all specimens were cycled between 2 and 10 Nm for 250 cycles. Reconstructed specimens continued to a torque test to catastrophic failure step. Outcome data included intracyclic stiffness, maximum cyclic rotational displacement, gap formation, and failure torque. RESULTS: Cyclic stiffness of the constructs remained constant throughout the entirety of the torque-controlled cycling phase. The DDA group resulted in a 38% increase in cyclic stiffness from native testing (not statistically significant) and a statistically significant 54% increase from the MD (P = .002). The DDA mean cyclic stiffness was significantly greater than the Native (P < .001), DD (P = .025), and MD (P < .001) groups. Between reconstruction groups, mean gap formation was greatest among the MD group (2.51° ± 1.59°) and least for the DDA group (1.01° ± 0.57°) but did not reach statistical significance. CONCLUSION: Tape augmentation to the modified UCLR (DDA group) improved cyclic stiffness and reduced gap formation compared with the MD group.

Is there a difference in outcomes between the first and second surgical procedures in patients who have bilateral shoulder operations?

BACKGROUND: Some patients who have shoulder surgery on 1 shoulder go on to have surgery on their contralateral shoulder. It is unclear whether the clinical improvements following the second surgical procedure are as significant as the improvements after the first surgical procedure. METHODS: All patients who underwent surgery on both shoulders performed by a single surgeon between March 2013 and June 2018 were eligible for inclusion. Visual analog scale (VAS) scores were obtained preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years for both shoulders. Scores were then compared based on hand dominance and which shoulder was treated first. Complications were also recorded. RESULTS: Overall, 105 patients (210 surgical procedures) were included. Of the patients, 66 underwent bilateral open shoulder surgery and 39 underwent bilateral arthroscopic shoulder surgery. There was a significant reduction in VAS scores from preoperative to postoperative levels following surgery (5.9 before surgery vs. 1.7 after surgery). We found no difference in VAS scores at any time point when comparing whether the dominant or nondominant shoulder was operated on first. Significantly higher VAS scores were observed at 2 weeks, 6 weeks, and 3 months following the first shoulder operation compared with the second; by 6 months and beyond, there was no longer a difference. CONCLUSION: Patients who undergo bilateral shoulder surgery have more pain in the first 3 months following their first shoulder operation compared with their second. However, there is no difference in pain scores at 6 months and beyond between shoulders.

What is the deviation in 3D preoperative planning software? A systematic review of concordance between plan and actual implant in reverse total shoulder arthroplasty.

BACKGROUND: Three-dimensional (3D) preoperative planning software for reverse total shoulder arthroplasty (rTSA) has been implemented in recent years in order to increase accuracy, improve efficiency, and add value to the outcome. A comprehensive literature review is required to determine the utility of preoperative 3D planning software in guiding orthopedic surgeons for implant placement in rTSA. We hypothesize that implementation of 3D preoperative planning software in the setting of rTSA leads to high concordance with minimal deviation from the preoperative plan. METHODS: A comprehensive and iterative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) using the PubMed, Embase, OVID Medline, Scopus, Cinahl, Web of Science, and Cochrane databases for original English-language studies evaluating the impact of preoperative planning software usage on rTSA outcomes published from January 1, 2000, to present. Blinded reviewers conducted multiple screens. All included studies were graded based on level of evidence, and data concerning patient demographics and postoperative outcomes were extracted. RESULTS: Nine articles met inclusion criteria (1 level II, 3 level III, and 5 level IV articles), including 415 patients and 422 shoulders. Of the patients who underwent rTSA, 235 were female and 140 were male, although 3 studies (n = 40) did not report sex breakdowns for rTSA patients. The average age was 72.7 years. Four studies (79 shoulders) reported implant final position as mean deviation from planned version and planned inclination. Six studies (n = 236) reported screw angle deviation, fixation, length, and concordance. Concordance with the preoperative plan was measured in 3 studies (n = 178), resulting in complete concordance of 90% (n = 100), arthroplasty type concordance (rTSA vs. TSA) of 100% (n = 100), and glenosphere size concordance between 93% (n = 100) and 88% (n = 76). For screw length concordance, baseplate screw matched by 81% (n = 76) and 100% (n = 2), and upper (n = 35) and lower (n = 35) screw length concordance was observed as 74% and 69%, respectively. The use of preoperative planning (n = 178) was associated with low deviation from preoperative plan, more 2-screw fixations, and longer average screw length in comparison with an unplanned cohort. CONCLUSION: The use of preoperative planning software in the setting of rTSA results in minimal deviation from preoperative plan. High levels of concordance in screw angle, screw length, and glenosphere size were observed. Further prospective studies should be conducted to further substantiate these results.

Is workload associated with latissimus dorsi and teres major tears in professional baseball pitchers? An analysis of days of rest, innings pitched, and batters faced.

BACKGROUND: Latissimus dorsi (LD) and teres major (TM) tears have become increasingly recognized injuries in professional baseball pitchers. The purpose of this study was to determine whether workload, as measured by the number of days of rest between outings, number of innings pitched, number of batters faced, and being a starting pitcher, is associated with an increased risk of sustaining an LD-TM tear in professional baseball pitchers. METHODS: All professional baseball pitchers who sustained an LD-TM tear between 2011 and 2017 were identified using the Major League Baseball Health and Injury Tracking System. A separate player-usage data set was used to determine workload. We then compared workload variables between pitcher-games 2, 6, 12, and >12 weeks prior to a documented LD-TM tear and pitcher-games from a non-LD-TM tear control group. In a paired analysis, we compared the acute workload (2, 6, and 12 weeks) prior to injury and the injured pitchers' non-acute workload >12 weeks prior to injury. RESULTS: A total of 224 unique LD-TM tears were documented in the Major League Baseball Health and Injury Tracking System database. In most periods, player-games with more innings pitched and more batters faced were associated with a higher incidence of subsequent LD-TM tears. The number of days of rest was not a significant predictor of an LD-TM tear in the acute workload setting, but pitchers who sustained an LD-TM injury averaged fewer days of rest over the previous ≥12 weeks than controls (P < .001). Pitchers who faced >30 batters per game showed a 1.57-fold increase in the percentage of pitchers with a subsequent LD-TM tear as compared with pitchers who faced ≤5 batters per game. Significantly more starting pitchers were in the case group that sustained LD-TM tears over multiple time points than in the control group. CONCLUSION: Having a greater pitcher workload and being a starting pitcher were associated with an increased risk of sustaining LD-TM tears in professional baseball players. The average number of days of rest was only a risk factor for LD-TM tears over a 3-month or longer period.

Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes.

BACKGROUND: Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers. PURPOSE: To report outcomes after UCLR in javelin throwers. HYPOTHESIS: UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports. METHODS: All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications. RESULTS: Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery. CONCLUSION: UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.

Prediction of total healthcare cost following total shoulder arthroplasty utilizing machine learning.

BACKGROUND: Given the increase in demand in treatment of glenohumeral arthritis with anatomic total (aTSA) and reverse shoulder arthroplasty (RTSA), it is imperative to improve quality of patient care while controlling costs as private and federal insurers continue its gradual transition toward bundled payment models. Big data analytics with machine learning shows promise in predicting health care costs. This is significant as cost prediction may help control cost by enabling health care systems to appropriately allocate resources that help mitigate the cause of increased cost. METHODS: The Nationwide Readmissions Database (NRD) was accessed in 2018. The database was queried for all primary aTSA and RTSA by International Classification of Diseases, Tenth Revision (ICD-10) procedure codes: 0RRJ0JZ and 0RRK0JZ for aTSA and 0RRK00Z and 0RRJ00Z for RTSA. Procedures were categorized by diagnoses: osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN), fracture, and rotator cuff arthropathy (RCA). Costs were calculated by utilizing the total hospital charge and each hospital's cost-to-charge ratio. Hospital characteristics were included, such as volume of procedures performed by the respective hospital for the calendar year and wage index, which represents the relative average hospital wage for the respective geographic area. Unplanned readmissions within 90 days were calculated using unique patient identifiers, and cost of readmissions was added to the total admission cost to represent the short-term perioperative health care cost. Machine learning algorithms were used to predict patients with immediate postoperative admission costs greater than 1 standard deviation from the mean, and readmissions. RESULTS: A total of 49,354 patients were isolated for analysis, with an average patient age of 69.9 ± 9.6 years. The average perioperative cost of care was $18,843 ± $10,165. In total, there were 4279 all-cause readmissions, resulting in an average cost of $13,871.00 ± $14,301.06 per readmission. Wage index, hospital volume, patient age, readmissions, and diagnosis-related group severity were the factors most correlated with the total cost of care. The logistic regression and random forest algorithms were equivalent in predicting the total cost of care (area under the receiver operating characteristic curve = 0.83). CONCLUSION: After shoulder arthroplasty, there is significant variability in cumulative hospital costs, and this is largely affected by readmissions. Hospital characteristics, such as geographic area and volume, are key determinants of overall health care cost. When accounting for this, machine learning algorithms may predict cases with high likelihood of increased resource utilization and/or readmission.

Patient Factors Associated With Clinical Failure Following Arthroscopic Superior Capsular Reconstruction.

PURPOSE: To identify demographic, clinical, and radiographic factors associated with failure after superior capsular reconstruction (SCR). METHODS: Prospectively collected data were analyzed from patients who underwent SCR using a decellularized dermal allograft for an irreparable rotator cuff tear. Demographic characteristics, radiographic findings, concomitant procedures, and patient-reported outcomes (PROs) were recorded. Failure was defined by ≥1 of the following criteria: (1) conversion to reverse total shoulder arthroplasty (RTSA), (2) a decrease in 1-year postoperative shoulder-specific PROs compared with preoperative scores, or (3) patient reports at final follow-up that the shoulder was in a worse condition than before surgery. Preoperative variables were compared between patients meeting the criteria for clinical failure and those who did not. RESULTS: Fifty-four patients (mean age 56.3 ± 5.8 years, range 45 to 70) who underwent SCR, with minimum 1-year follow-up, were included in the analysis. Mean follow-up after surgery was 24 months (range 12 to 53). Eleven patients (20.4%) met criteria for clinical failure. Of the 11, 8 reported decreased American Shoulder and Elbow Surgeons (ASES) or Constant scores or indicated that the operative shoulder was in a worse condition than before surgery. Three patients underwent RTSA in the 6 to 12 months after SCR. Female sex and the presence of a subscapularis tear were associated with failure (P = .023 and P = .029, respectively). A trend toward greater body mass index (BMI), lower preoperative forward flexion, and lower preoperative acromiohumeral distance (AHD) was found in patients with clinical failure (P = .075, P = .088, and P = .081, respectively). No other variable included in the analysis was significantly associated with failure. CONCLUSION: The proportions of female patients and those with subscapularis tear were greater among patients with clinical failure after SCR. Greater BMI, lower preoperative forward flexion, and lower preoperative AHD trended toward association with clinical failure of SCR. LEVEL OF EVIDENCE: 4, case series.

Randomized Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-Reported Outcomes at Long-Term Follow-Up.

PURPOSE: To evaluate long-term patient-reported outcomes and revision surgery after arthroscopic rotator cuff repair with or without acromioplasty. METHODS: Between 2007 and 2011, prospectively enrolled patients undergoing arthroscopic repair for full-thickness rotator cuff tears, with any acromial morphology, were randomized into either acromioplasty or nonacromioplasty groups. Patients with revision surgery, subscapularis involvement, advanced neurologic conditions, or death were excluded. Baseline and long-term follow-up questionnaires, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA), Visual Analog Scale (VAS) for pain, and Constant scores were obtained. Rates of symptomatic retear, revision rotator cuff surgery, or secondary reoperation were recorded. Averages with standard deviation were calculated, and t-tests were used to compare outcomes of interest between cohorts. RESULTS: In total, 69 of 90 patients (76.7%) were available at 92.4 months (± 10.5). There were 23 of 32 patients in the acromioplasty cohort and 24 of 37 patients in the nonacromioplasty cohort. Mean age for the nonacromioplasty cohort was 56.9 (± 7.6) years, whereas acromioplasty was 59.6 (± 6.8) years. Comparison of baseline demographics and intraoperative information revealed no significant differences, including age, sex, Workers' Compensation, acute mechanism of injury, tear size, degree of retraction, and surgical technique (e.g., single- vs. double-row). At final follow-up, there were no statistically significant differences according to ASES (P = .33), VAS pain (P = 0.79), Constant (P = .17), SST (P = .05), UCLA (P = .19), and Short Form-12 (SF-12) (P = .79) in patients with and without acromioplasty. Two patients with acromioplasty (5.6%) and 3 patients without acromioplasty (9.1%) sustained atraumatic recurrent rotator cuff tear with secondary repair (P = .99), and there was no significant difference in retear rates or patient-reported outcome measures by acromial morphology. CONCLUSIONS: This randomized trial, with mean 7.5-year follow-up, found no difference in validated patient-reported outcomes, retear rate, or revision surgery rate between patients undergoing rotator cuff repair with or without acromioplasty. LEVEL OF EVIDENCE: II, prospective randomized controlled trial.

Management of Shoulder Instability in 2020: What, When, and How.

Anterior glenohumeral instability remains a common clinical problem in the athletic and working patient populations, and further, recurrence rates following stabilization surgery continue to be problematic. Over the past 5 years, there have been substantial improvements in the understanding of anterior shoulder instability. To better counsel and treat patients, it is imperative for surgeons to have a comprehensive understanding of the epidemiology of shoulder instability, the anatomy of the glenohumeral joint particularly as it relates to glenoid and humeral head bone loss, surgical indications, and surgical techniques. These critical topics are summarized in an effort to provide a complete guide to managing anterior shoulder instability in 2020.

Surgeon acceptance of an initial 3D glenoid preoperative plan: rates and risk factors.

BACKGROUND: Although the effect of 3-dimensional (3D) planning for total shoulder arthroplasty (TSA) on component positioning and patient outcomes has been increasingly studied, the effect of 3D planning on surgeon decision making has not been well studied. METHODS: A retrospective review was performed of a database containing TSA cases for which the glenoid component was planned with a commercially available 3D computed tomography software program (Virtual Implant Positioning; Arthrex, Inc.) from 2016 to 2019. A total of 6483 cases planned by 417 surgeons were included. The glenoid version (Vtech) and inclination (Itech) of the Virtual Implant Positioning technician plan as well as the surgeon's final plan for version (Vsurg) and inclination (Isurg) were extracted. When the version and/or inclination of the surgeon plan matched that of the technician, that variable was defined as "accepted." The rates of acceptance of Vtech and Itech were calculated and analyzed for association with implant type, native version and inclination, and running case count. A subgroup analysis of high-volume users (n > 30 cases) was analyzed to determine if any of the variables independently was associated with surgeon acceptance. RESULTS: There was a very high rate of matching of version (66%), inclination (72%), or both (55%) and a low rate (18%) where neither parameter of the glenoid plan matched that of the technician. In univariate analysis, as the case count and retroversion increased the rate of accepting of version dropped noticeably (70%-50% and 47%, respectively [ P< .0001]). The rate of accepting the plan for inclination did not vary much as case count changed. In the multivariate analysis, 23 of 56 high-volume surgeons had at least 1 independent factor associated with accepting the technician-planned glenoid version, and 5 surgeons had 2 independent factors. In the multivariate analysis of matching glenoid inclination, 27 of 56 high-volume surgeons had at least 1 independent factor associated with accepting the technician-planned glenoid version, and 9 surgeons had 2 or more independent factors. CONCLUSIONS: In a large database of TSAs with 3D-planned glenoids, there were high rates of cases with surgeon agreement with an initial plan provided by an industry technician: 66% in version, 72% in inclination, 55% for both version and inclination. Surgeon acceptance of the initial plan decreased as pathoanatomy increased and case count increased. Shoulder surgeons should be aware that an initial 3D preoperative plan provided by industry represents a potential source of cognitive bias in shoulder arthroplasty planning.

Does commercially available shoulder arthroplasty preoperative planning software agree with surgeon measurements of version, inclination, and subluxation?

BACKGROUND: Preoperative planning with commercially available imaging software in shoulder arthroplasty may allow for improved decision-making and more accurate placement of the glenoid component. METHODS: A total of 81 consecutive shoulder computed tomography scans obtained for preoperative planning purposes for shoulder arthroplasty were analyzed by commercially available software from 4 companies (Blueprint: Wright Medical, Memphis, TN, USA; GPS: Exactech, Gainesville, FL, USA; Materialise: DJO, Vista, CA, USA; and VIP: Arthrex, Naples, FL, USA) and by 5 fellowship-trained sports medicine/shoulder surgeons. Inclination, version, and subluxation of the humerus were measured in a blinded fashion on axial and coronal sequences at the mid-glenoid. Surgeon measurements were analyzed for agreement and were compared with the 4 commercial programs. RESULTS: Surgeon reliability was acceptable for version (intraclass correlation coefficient [ICC]: 0.876), inclination (ICC: 0.84), and subluxation (ICC: 0.523). Significant differences were found between surgeon and commercial software measurements in version (P = .03), inclination (P = .023), and subluxation (P < .001). Software measurements tended to be more superiorly inclined (average -2° to 2° greater), more retroverted (average 2°-5° greater), and more posteriorly subluxed (average 7°-10° greater) than surgeon measurements. In comparing imaging software measurements, only Blueprint was found to produce significantly different version measurements than surgeon measurements (P = .02). CONCLUSION: Preoperative planning software for shoulder arthroplasty has limited agreement in measures of version, inclination, and subluxation measurements, whereas surgeons have high inter-reliability. Surgeons should be cautious when using commercial software planning systems and when comparing publications that use different planning systems to determine preoperative glenoid deformity measurements.

Early postoperative complications after Latarjet procedure: a single-institution experience over 10 years.

BACKGROUND: The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications. METHODS: This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence. RESULTS: During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P < .001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1 brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases. CONCLUSION: The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.

Efficacy of the modified Frailty Index and the modified Charlson Comorbidity Index in predicting complications in patients undergoing operative management of proximal humerus fracture.

BACKGROUND: Comorbidity indices such as the 5-factor modified Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI) are widely used in outcomes research. METHODS: A total of 3893 patients who underwent total shoulder arthroplasty (n=975), hemiarthroplasty (n=495), or open reduction and internal fixation (n=2423) for the treatment of proximal humerus fracture from 2005-2017 were identified from the National Surgical Quality Improvement Program database. Data regarding demographics, comorbidities, American Society of Anesthesiologists class, and postoperative complications were collected, and the mFI-5 and mCCI were calculated for each case. Multivariate logistic regression models and receiver operating characteristic curve analyses were performed. RESULTS: The patient population had a mean age of 68.0 ± 13.2 years, body mass index of 29.1 ± 8.1 and mean operative time of 119.9 ± 55.5 minutes. The most common complications within this cohort were extended length of stay (4 days or more) (1085/3893; 27.87%), transfusion (377/3893; 9.68%), unplanned reoperation (97/3893; 2.49%), urinary tract infection (43/3893; 1.10%), death (42/3893; 1.08%), and deep vein thrombosis (40/3893; 1.03%). After accounting for patient demographics, the mFI-5 (odds ratio [OR] = 1.105, P < .001) and mCCI (OR = 1.063, P < .001) were significantly associated with incidence of any adverse event. Both comorbidity indices had low positive predictive value and high negative predictive value for all adverse events. CONCLUSION: The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures.

Biconcave glenoids show 3 differently oriented posterior erosion patterns.

BACKGROUND: Posterior glenoid wear remains a challenge in anatomic and reverse total shoulder arthroplasty (rTSA) because of an asymmetric erosion with altered retroversion. The purpose of this study was to assess glenoid morphology and evaluate the influence of acromial orientation in posterior glenoid erosion patterns by using 3-dimensional (3D) models. MATERIAL AND METHODS: Computed tomographic (CT) shoulder scans from 3 study centers of patients awaiting rTSA between 2017 and 2018 were converted into 3D models and analyzed by 2 observers. Morphology, orientation and greatest depth of erosion, inclination, current retroversion and premorbid retroversion, surface areas of the glenoid, and external acromial orientation and posterior acromial slope were assessed. Measurements were compared between wear patterns, glenoid erosion entities, and genders. RESULTS: In the complete cohort of 68 patients (63.8 ± 10.0 years; 19 female, 49 male), a mean of 85.9° (±22.2°) was observed for the glenoid erosion orientation. Additionally, a further distinct classification of the glenoid erosion as posterior-central (PC, n = 39), posterior-inferior (PI, n = 12), and posterior-superior (PS, n = 17) wear patterns was possible. These wear patterns significantly (P < .001) distinguished by erosion orientation (PC = 86.9° ± 12.0°, PI = 116.3° ± 10.3°, PS = 62.3° ± 18.9°). The greatest depth of erosion found was 7.3 ± 2.7 mm in PC wear patterns (PC vs. PI: P = .03; PC vs. PS: n.s.; PI vs. PS: n.s.). Overall, the observed erosion divided the glenoid surface into a paleoglenoid proportion of 48% (±11%) and a neoglenoid proportion of 52% (±12%). For the complete cohort, glenoid inclination was 85.4° (±6.6°), premorbid glenoid retroversion was 80.7° (±8.1°), and current glenoid retroversion was 73.4° (±7.4°), with an estimated increase of 6.9° (±6.0°). The mean external acromial orientation was 118.2° (±8.9°), and the mean posterior acromial slope was 107.2° (±9.6°). There were no further significant differences if parameters were compared by wear patterns, entities, and gender. CONCLUSION: Three significantly differently oriented wear patterns (posterior-superior, posterior-central, and posterior-inferior) were distinguished in shoulders demonstrating posterior wear on axillary imaging. No significant differences between the observed erosion patterns or any relevant correlations were found regarding the orientation of the acromion.

Return to sport following Latarjet glenoid reconstruction for anterior shoulder instability.

BACKGROUND: Latarjet coracoid transfer reconstruction is the gold standard for the treatment of recurrent shoulder instability with anterior-inferior glenoid bone loss, and return to sport is often a primary outcome of interest in this patient population. The purpose of this study was to determine the rate of return to sport in patients undergoing the Latarjet procedure and variables that are associated with a higher likelihood of a successful return to sport. METHODS: A prospectively maintained institutional registry was retrospectively queried between August 2012 and August 2016 for all patients who underwent the Latarjet procedure. Patients were contacted electronically and via telephone to administer a previously validated and standardized return-to-sport survey. Patients self-reported return to sport, varying sports participation, recurrence of instability, and time to return to sport. Multivariate analysis was performed to determine variables associated with each outcome. RESULTS: Of 83 patients, 66 (75.3%) were available for final follow-up, of whom 60 participated in sports prior to surgery and were eligible for inclusion. The average follow-up period was 53.8 ± 11.8 months. The average age at surgery was 26.7 ± 11.3 years, and the average body mass index was 26.2 ± 4.0 kg/m2. There were 54 patients (90%) who were able to return to sport at an average of 8.6 ± 4.1 months following surgery. In total, 36 patients (60%) were able to return to sport at the same level or a better level of intensity, 19 of 28 patients (67.9%) were able to return to throwing sports without difficulty, and 31 of 60 patients (51.7%) reported that their shoulder was a hindrance to some activity. An increased likelihood of returning to sport was associated with increased body mass index (P = .016), male sex (P = .028), and decreased humeral bone loss volume (P = .034). An increased likelihood of returning to sport at the same level or a better level of intensity was associated with reduced humeral bone loss volume (P = .026). Recurrent instability was associated with humeral bone loss (P = .038). CONCLUSION: Although a large majority of patients were able to return to sport following the Latarjet procedure, some patients experienced limitation with throwing and return to sport at the preinjury level. Greater humeral bone loss was associated with inferior outcomes. These findings should be discussed with patients in the preoperative setting to manage expectations appropriately.