Postoperative Graft Volume Reduction Is Associated With Inferior Clinical Outcomes of Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft.

PURPOSE: To evaluate whether postoperative graft volume reduction is associated with clinical outcomes after superior capsule reconstruction (SCR) and to identify factors related to graft volume change. METHODS: Between May 2018 and June 2021, patients who underwent SCR with acellular dermal matrix allograft for irreparable rotator cuff tear with a minimum 1-year follow-up and who had intact graft continuity in postoperative 6-month magnetic resonance imaging were retrospectively reviewed. The lateral half to the medial half of the graft volume ratio was defined as lateral half graft volume ratio. The difference between the preoperative and postoperative lateral half graft volume ratio was defined as lateral half graft volume change. Patients were divided into 2 groups: those with preserved graft volume (group I) and those with reduced graft volume (group II). Intergroup differences in clinical and radiological characteristics were analyzed. RESULTS: A total of 81 patients were included, with 47 (58.0%) in group I and 34 (42.0%) in group II. Group I showed significantly lower lateral half graft volume change (0.018 ± 0.064 vs 0.370 ± 0.177; P < .001) than group II. Group II showed significantly greater preoperative Hamada grade (1.3 ± 0.5 vs 2.2 ± 0.6, P < .001), an anteroposterior distance of the graft at the greater tuberosity (APGT) (30.3 ± 4.8 vs 35.2 ± 3.8, P < .001), and fatty infiltration of infraspinatus (2.3 ± 0.9 vs 3.1 ± 0.8, P < .001) and subscapularis (0.9 ± 0.9 vs 1.6 ± 1.3, P = .009) than group I. Group II had a significantly lower proportion of patients achieving MIC in Constant score than group I (70.2% vs 47.1%, P = .035). The Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were independent factors of graft volume change. CONCLUSIONS: Although SCR improved pain and shoulder function, postoperative graft volume reduction was related to a lower rate of minimal important change achievement in the Constant score compared with preserved graft volume. The preoperative Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were associated with graft volume reduction. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

No Difference In Clinical Outcomes Following Repair of Large Retracted Anterior Rotator Cuff Tears Using Patch Augmentation With Human Dermal Allograft Versus Anterior Cable Reconstruction With Biceps Tendon Autograft.

PURPOSE: To compare the clinical outcomes and tendon integrity after rotator cuff repair combined with anterior cable reconstruction (ACR) using the proximal biceps tendon and patch augmentation (PA) using a human dermal allograft (HDA) in a large retracted anterior rotator cuff tear. METHODS: Patients who underwent arthroscopic rotator cuff repair with 2 different augmentation procedures between January 2017 and December 2020 were enrolled. The inclusion criteria were patients who were treated by arthroscopic rotator cuff repair with ACR using the proximal biceps tendon (ACR group) or patch augmentation using a an HDA (PA group) and follow-up for at least 2 years. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) score, Constant score, and the number of patients who achieved minimal clinically important differences (MCID). Magnetic resonance imaging was performed to evaluate tendon integrity after surgery. RESULTS: A total of 92 patients were enrolled (ACR group = 55 patients and PA group = 37 patients). The mean ASES and Constant scores significantly improved in the ACR group (68.8 ± 15.3 and 58.4 ± 16.9 before surgery vs 91.4 ± 6.3 and 87.8 ± 6.0 after surgery, P < .001) and in the PA group (63.7 ± 16.7 and 57.9 ± 15.4 before surgery vs 93.1 ± 6.3 and 88.3 ± 6.2 after surgery, P < .001). Overall, 78 patients (84.8%) achieved the MCID with 81.8% in the ACR group and 89.2% in the PA group, with no significant differences between the 2 groups (P = .638). Ten patients (18.2%) had retear in the ACR group, and three patients (8.1%) had retear in the PA group (P = .174). CONCLUSIONS: In large retracted anterior rotator cuff tears, both augmentation techniques using biceps tendon autograft and HDA provided satisfactory clinical outcomes that achieved the MCID in 84.8%, range of motion restoration, and lower retear rates with no significant differences between the two groups. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Occult, Incomplete, and Complete Posterior Labral Tears Without Glenohumeral Instability on Imaging Underestimate Labral Detachment.

PURPOSE: To introduce a classification of posterior labral tear and describe clinical characteristics, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA) findings, arthroscopic findings, and outcomes after arthroscopic repair for patients with posterior labral tears without glenohumeral instability. METHODS: Sixty patients with posterior labral tear who underwent arthroscopic repair were analyzed retrospectively. Patients with shoulder instability were excluded. Tear patterns were classified into 3 types; occult (type 1), incomplete (type 2), and complete (type 3) based on MRI/MRA studies. A visual analog scale score for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score for satisfaction, and return to sports were evaluated at a minimum follow-up of 2 years. Computed tomography arthrography was performed at a year follow-up for assess labral healing. The diagnosis was confirmed in arthroscopy, and arthroscopic labral repair without capsular plication was performed. RESULTS: The mean patient age was 30.4 ± 6.9 years, and all patients were male. Forty-four patients (73.3%) were participating in sports. MRI/MRA studies identified 10 patients with type 1, 18 with type 2, and 32 with type 3 tears. Type 1 tear patients showed a significantly longer symptom duration than those with type 3 (32.5 ± 17.2 vs 18.2 ± 17.1 months; P = .015). In arthroscopic findings, 70% of type 1 tear was confirmed as incomplete or complete tears. The American Shoulder and Elbow Surgeons score improved from 79.6 ± 10.3 to 98.1 ± 3.7, and pain was relieved from 2.4 ± 0.7 to 0.2 ± 0.5 at the last follow-up visit with high labral healing rate (95%). Thirty-nine (88.6%) patients returned to sports at preinjury levels. CONCLUSIONS: In active young men with shoulder pain during daily activities or sports despite programmed conservative treatment, posterior labral tears should be considered even when MRI/MRA findings are ambiguous. Arthroscopic posterior labral repair without capsular plication provided satisfactory clinical outcomes and a high labral healing rate. LEVEL OF EVIDENCE: Level Ⅳ, case series.

Arthroscopic suprapectoral biceps tenodesis provided earlier shoulder function restoration compared with open subpectoral biceps tenodesis during the recovery phase.

BACKGROUND: This study compared the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral biceps tenodesis for symptomatic biceps tenosynovitis. Although both techniques have pros and cons, no studies have compared clinical and functional outcomes during the recovery phase. Previous studies show that suprapectoral tenodesis has a higher probability of Popeye deformity and postoperative bicipital pain and stiffness, whereas subpectoral tenodesis has a higher risk of nerve complications and wound infections. This study aimed for clinical comparison between arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis. METHODS: This study is a retrospective review of institutional records of patients with biceps tendinitis who underwent open or arthroscopic biceps tenodesis. Surgical indications included biceps tenosynovitis, biceps partial tear, and biceps pulley lesion. Patients with prior shoulder surgery, preoperative shoulder stiffness, or full-thickness tear of rotator cuff were excluded. Tenodesis was considered when the pain recurs within 3 months despite conservative treatment including at least 2 triamcinolone injections on the biceps tendon sheath. Visual analog scale (VAS) score for pain, presence of the night pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and range of motion were assessed preoperatively at 3, 6, 12, and 24 months postoperatively and the last follow-up. RESULTS: A total of 72 patients (33 with arthroscopic suprapectoral biceps tenodeses and 39 with open subpectoral biceps tenodeses) were included in analysis. At postoperative 6 months, lower VAS score (0.4 ± 0.8 vs. 1.7 ± 1.9, P < .001), and the presence of the night pain (2 [6%] vs. 14 [36%], P = .002), ASES score (89.6 ± 9.2 vs. 81.4 ± 14.6, P = .006), and Constant score (89.4 ± 5.6 vs. 82.0 ± 12.5, P = .003) compared with the subpectoral group. The mean number of postoperative steroid injections for pain control in the subpectoral group (0.51 ± 0.80) was significantly higher than that in the suprapectoral group (0.18 ± 0.40) (P = .031). However, postoperative clinical outcomes were restored similar between the 2 groups at 12 months and the last follow-up. DISCUSSION: Arthroscopic suprapectoral biceps tenodesis performed statistically better than the subpectoral biceps tenodesis for the VAS, ASES, night pain, and Constant score at postoperative 6 months. However, only night pain and the Constant score showed differences that exceeded minimum clinically important difference during the recovery phase. At postoperative 12 and 24 months, biceps tenodesis provided satisfactory clinical outcomes and pain relief regardless of the fixation technique and suture anchor location.

Arthroscopic-Assisted Double-Bundle Coracoclavicular Ligament Reconstruction Using Cortical Fixation Buttons With Suture Tape Provides Superior Vertical Stability Than the Single-Bundle Reconstruction for Acute Acromioclavicular Joint Dislocation.

PURPOSE: This study aimed to compare clinical and radiologic outcomes between single- and double-bundle arthroscopic-assisted coracoclavicular (CC) ligament reconstruction using cortical fixation buttons with suture tapes for acute acromioclavicular (AC) joint dislocation. METHODS: Patients who underwent arthroscopic-assisted CC ligament reconstruction using cortical fixation buttons with suture tapes for acute AC joint dislocation from July 2014 to March 2019 were identified. This study included patients treated for acute AC joint dislocation within 2 weeks after an injury, with a Rockwood classification of III or V and at least 2 years of follow-up. Patients were divided into 2 groups based on the reconstruction technique: group I (single-bundle technique) and group II (double-bundle technique). The clinical outcomes were compared using the American Shoulder Elbow Surgeons (ASES) score, Constant score, and visual analog scale for pain score between the 2 groups. On the plain radiograph, the CC interval ratio (CCIR) was measured to evaluate maintenance of CC interval fixation. Postoperative complications, including reduction failure, were also documented. RESULTS: Fifty-eight patients (26 in group I, 32 in group II) were enrolled. There were no significant differences in CCIR between the 2 groups preoperatively and 3 months postoperatively. However, the CCIR of group I was significantly greater than that of group II 6 months postoperatively (group I: 160.5% ± 48.5%, group II: 125.4% ± 38.9% at 6 months postoperatively, P = .01; group I: 164.0% ± 57.3%, group II: 123.2% ± 35.9% at the last visit, P = .01). Despite radiologic differences, the clinical outcomes demonstrated no significant differences between 2 the groups (ASES score: 93.5 ± 5.2 in group I, 94.4 ± 4.5 in group II, P = .54; Constant score: 92.9 ± 5.3 in group I, 94.8 ± 4.3 in group II, P = .16). Reduction failure occurred in 4 patients (15.3%) in group I and in 1 patient (3.2%) in group II (P = .16). CONCLUSIONS: Arthroscopic-assisted double-bundle CC ligament reconstruction using cortical fixation buttons with suture tapes provided superior vertical stability than the single-bundle technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intravenous Versus Perineural Dexamethasone for Reducing Rebound Pain After Interscalene Brachial Plexus Block: A Randomized Controlled Trial.

BACKGROUND: Interscalene brachial plexus block (ISB) is a common regional technique to manage acute postoperative pain for arthroscopic rotator cuff tear repair. However, rebound pain may compromise its overall benefit. Our aim was to investigate the primary hypothesis that perineural and intravenous dexamethasone have different effects on rebound pain after resolution of ISB for arthroscopic rotator cuff tear repair. METHODS: Patients aged ≥ 20 years scheduled for elective arthroscopic rotator cuff tear repair under general anesthesia with preoperative ISB were included. The participants were randomized to receive dexamethasone either perineurally (perineural group) or intravenously (intravenous group). In the perineural group, patients received ISB with 12 mL of 0.5% ropivacaine containing 5 mg of dexamethasone; simultaneously, 1 mL of 0.9% normal saline was administered intravenously. In the intravenous group, patients received ISB with 12 mL of 0.5% ropivacaine; simultaneously, 1 mL of dexamethasone 5 mg was administered intravenously. The primary outcome was the difference in the pain score (0-10 on numeric rating scale) between before and after ISB resolution. The secondary outcomes were the incidence of rebound pain; onset, duration, and intensity of rebound pain; time to the first analgesic request; and pain-related sleep disturbance. RESULTS: A total of 71 patients were randomized to either perineural group (n = 36) or intravenous group (n = 35). After block resolution, pain scores increased significantly more in the perineural group (mean ± standard deviation, 4.9 ± 2.1) compared to the intravenous group (4.0 ± 1.7, P = 0.043). The duration of ISB was more prolonged in the perineural group (median [interquartile range], 19.9 [17.2-23.1] hours) than the intravenous group (15.1 [13.7-15.9] hours, P < 0.001). The incidence of rebound pain and pain-related sleep disturbance during the first postoperative week was significantly higher in the perineural group than in the intravenous group (rebound pain: 44.4% vs. 20.0%, P = 0.028; sleep disturbance: 55.6% vs. 25.7%, P = 0.011). The duration and intensity of rebound pain were similar between the two groups. CONCLUSION: Although perineural dexamethasone provided longer postoperative analgesia, intravenous dexamethasone was more beneficial in reducing pain increase after ISB resolution, incidence of rebound pain, and pain-related sleep disturbance. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0006795.

Arthroscopic double-row bridge fixation provided satisfactory shoulder functional restoration with high union rate for acute anterior glenoid fracture.

PURPOSE: To introduce a novel surgical technique for arthroscopic reduction and double-row bridge fixation using trans-subscapularis tendon portal for anterior glenoid fracture and to evaluate the clinical and radiological outcomes. METHODS: A total of 22 patients who underwent arthroscopic reduction and double-row bridge fixation for an acute anterior glenoid fracture were retrospectively evaluated. Arthroscopic surgery was performed using four portals including a trans-subscapularis tendon portal. All patients underwent 3D-CT preoperatively and one day and one year postoperatively to evaluate the fracture fragment size, reduction status, and presence of fracture union. To evaluate the degree of fragment displacement, articular step-off and medial fracture gap were measured using 3D-CT. Clinical outcomes were assessed based on the ASES and Constant scores. Postoperative glenohumeral joint arthritis was evaluated using plain radiographs with the Samilson and Prieto classification. RESULTS: The average preoperative fracture fragment size was 25.9 ± 5.6%. Articular step-off (preoperative: 6.0 ± 3.3 mm, postoperative one day: 1.1 ± 1.6 mm, P < 0.001) and medial fracture gap (preoperative: 5.2 ± 2.6 mm, postoperative one day: 1.9 ± 2.3 mm, P < 0.001) were improved after surgery. On the postoperative one year 3D-CT, 20 patients achieved complete fracture union, and two patients showed partial union. Postoperative glenohumeral joint arthritis was observed in four patients. At the last visit, the ASES score was 91.8 ± 7.0 and the Constant score was 91.6 ± 7.0. CONCLUSION: Arthroscopic reduction and double-row bridge fixation using a trans-subscapularis tendon portal for acute anterior glenoid fracture achieved satisfactory clinical outcomes and anatomical reduction as demonstrated by a low degree of articular step-off and medial fracture gap. LEVEL OF EVIDENCE: Level IV.

Satisfactory functional and structural outcomes of anterior cable reconstruction using the proximal biceps tendon for large retracted rotator cuff tears.

PURPOSE: Large retracted anterior L-shaped tear characterized by a retracted supraspinatus tendon to the glenoid level combined with a relatively preserved infraspinatus tendon is one of the challenging tear patterns in achieving complete repair to the anatomic footprint. The purpose of this study was to evaluate clinical outcomes and tendon integrity of rotator cuff repair combined with anterior cable reconstruction using the proximal biceps tendon in patients with large retracted anterior L-shaped rotator cuff tear. METHODS: This study prospectively enrolled patients who underwent arthroscopic anterior cable reconstruction using the proximal biceps tendon for large retracted anterior L-shaped rotator cuff tears between 2018 and 2020 with a minimum 2-year follow-up. The anterior portion of the rotator cable was reconstructed using tenotomized proximal biceps tendon fixed with two suture anchors at the footprint. The retracted supraspinatus tendon was repaired on the biceps tendon without undue tension. The proximal portion of the infraspinatus tendon was repaired with the biceps tendon-supraspinatus tendon complex. Clinical outcomes was assessed during the follow-up period. Tendon integrity and retear size were evaluated by postoperative MRI. RESULTS: A total of 32 consecutive patients were included. The ASES score was significantly improved from 66.6 ± 16.6 preoperatively to 94.1 ± 6.1 postoperatively (P < 0.001), and the VAS for pain was significantly relieved from 2.8 ± 1.9 preoperatively to 0.5 ± 0.4 postoperatively (P < 0.001). All patients were satisfied postoperatively regardless of tendon integrity (P = 0.015). Postoperative ROM was increased continuously during the follow-up period (P < 0.001). The Popeye sign was found in 4 patients (12.5%). Six patients (18.7%) had rotator cuff retears. However, the ASES score of patients with retear was significantly improved from 72.8 ± 13.3 preoperatively to 91.1 ± 6.7 postoperatively (P < 0.001). Relative changes in the retear size compared with the primary tear size were -56.8 ± 14.4% for the anteroposterior diameter and - 70.6 ± 6.1% for the mediolateral diameter. CONCLUSIONS: Rotator cuff repair combined with anterior cable reconstruction using the proximal biceps tendon provided satisfactory clinical and radiological outcomes for large retracted anterior L-shaped tears. Anterior cable reconstruction using the proximal biceps tendon is a sound surgical option for the patients with large retracted anterior rotator cuff tear. LEVEL OF EVIDENCE: IV.

The biomechanical effects of acromial fracture angulation in reverse total shoulder arthroplasty.

BACKGROUND: The biomechanical changes and treatment guidelines on acromial fracture after reverse shoulder arthroplasty (RSA) are still not well understood. The purpose of our study was to analyze the biomechanical changes with respect to acromial fracture angulation in RSA. METHODS: RSA was performed on 9 fresh-frozen cadaveric shoulders. An acromial osteotomy was performed on the plane extending from the glenoid surface to simulate an acromion fracture. Four conditions of acromial fracture inferior angulation were evaluated (0°, 10°, 20°, and 30° angulation). The middle deltoid muscle loading origin position was adjusted based on the position of each acromial fracture. The impingement-free angle and capability of the deltoid to produce movement in the abduction and forward flexion planes were measured. The length of the anterior, middle, and posterior deltoid was also analyzed for each acromial fracture angulation. RESULTS: There was no significant difference in the abduction impingement angle between 0° (61.8° ± 2.9°) and 10° angulation (55.9° ± 2.8°); however, the abduction impingement angle of 20° (49.3° ± 2.9°) significantly decreased from 0° and 30° angulation (44.2° ± 4.6°), and 30° angulation significantly differed from 0° and 10° (P < .01). On forward flexion, 10° (75.6° ± 2.7°), 20° (67.9° ± 3.2°), and 30° angulation (59.8° ± 4.0°) had a significantly decreased impingement-free angle than 0° (84.2° ± 4.3°; P < .01), and 30° angulation had a significantly decreased impingement-free angle than 10°. On analysis of glenohumeral abduction capability, 0° significantly differed (at 12.5, 15.0, 17.5, and 20.0N) from 20° and 30°. For forward flexion capability, 30° angulation showed a significantly smaller value than 0° (15N vs. 20N). As acromial fracture angulation increased, the middle and posterior deltoid muscles of 10°, 20°, and 30° became shorter than those of 0°; however, no significant change was found in the anterior deltoid length. CONCLUSIONS: In acromial fractures at the plane of glenoid surface, 10° inferior angulation of the acromion did not interfere with abduction and abduction capability. However, 20° and 30° of inferior angulation caused prominent impingement in abduction and forward flexion and reduced abduction capability. In addition, there was a significant difference between 20° and 30°, suggesting that not only the location of the acromion fracture after RSA but also the degree of angulation are important factors for shoulder biomechanics.

Effects of neuromuscular electrical muscle stimulation on the deltoid for shoulder function restoration after reverse total shoulder arthroplasty in the early recovery period: a prospective randomized study.

INTRODUCTION: Neuromuscular electrical stimulation (NMES) is a treatment modality that has been used to accelerate the rehabilitation of patients with neurological damage. However, it is unclear whether NMES of the deltoid can lead to the early restoration of shoulder function after reverse total shoulder arthroplasty (RSA). MATERIALS AND METHODS: In this prospective and randomized study, 88 patients who underwent RSA with the same prosthesis design for cuff tear arthropathy or irreparable rotator cuff tear were assessed. The patients were divided into two groups (NMES group and non-NMES group, 44 patients each). For the NMES group, two pads of the NMES device were placed over the middle and posterior deltoid area, and NMES was maintained for 1 month after surgery. Shoulder functional outcomes and deltoid thickness were compared at 3, 6, and 12 months postoperatively. Shoulder functional outcomes were assessed based on the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES), and Constant scores and the range of motion (ROM) and power of the affected shoulder. The thickness of the anterior, middle, and posterior deltoid was measured by ultrasonography. RESULTS: A total of 76 patients (NMES group, 33 patients; non-NMES group, 43 patients) were enrolled in the final analysis. The preoperative demographics and status of the remaining rotator cuff of both groups were not significantly different. At postoperative 3 months, the ROM and power of external rotation of the NMES group were significantly greater than those of the non-NMES group (ROM, 36° ± 14° vs. 29° ± 12°; P = .003; power, 4.8 kg ± 1.8 kg vs. 3.8 kg ± 1.0 kg; P < .002). The ROM of external rotation of the NMES group at postoperative 6 months was also greater than that of the non-NMES group (41° ± 12° vs. 34° ± 11°; P = .013). However, there was no significant difference in the VAS, ASES, and Constant scores at all follow-up points despite gradual improvements until 1 year postoperatively. Serial measurements of the thickness of the anterior, middle, and posterior deltoid of both groups did not show significant differences. CONCLUSIONS: Postoperative NMES of the deltoid after RSA contributed to significantly faster ROM restoration and considerable improvement in the power of external rotation. Therefore, NMES following RSA could lead to the early restoration of external rotation and recovery of deltoid function.

Superior Capsular Reconstruction Using Acellular Dermal Allograft Combined With Remaining Rotator Cuff Augmentation Improved Shoulder Pain and Function at 1 Year After The Surgery.

PURPOSE: The purpose of this study is to report structural integrity and clinical outcomes of superior capsular reconstruction (SCR) using a 4- to 5-mm acellular dermal allograft combined with augmentation of the remaining rotator cuff to the graft. METHODS: We prospectively recruited 21 patients with symptomatic irreparable rotator cuff tear who required SCR. At least 6 months after the SCR, we evaluated each patient's graft healing by magnetic resonance imaging (MRI). We also assessed the range of motion (ROM), strength for forward flexion and external rotation, visual analog scale for pain (PVAS), American Shoulder and Elbow Surgeon (ASES) score, and Constant score. At minimum of 1 year after the surgery, we evaluated the number of patients with minimal clinically important differences (MCIDs) for each score to compare patients with healed and unhealed grafts. RESULTS: Postoperative MRI showed the grafts intact in 14 patients (66.7%). Among 7 patients with unhealed grafts, tears were observed in 3 patients (42.9%) on the glenoid side, 3 (42.9%) on the humeral side, and 1 (14.3%) on both sides. PVAS, ASES score, and the Constant score improved after surgery (4.0 to 0.7 for PVAS [P < .001], 55.5 to 87.0 for ASES score [P < .001], and 56.0 to 65.9 for Constant score [P = .007]). However, there were no differences in postoperative ROM and muscle strength compared to preoperative measurements. MCIDs were reached in 90.5% of patients (n = 19) for the PVAS and in 71.4% of patients (n = 15) for the ASES score. Only 33.3% of patients (n = 7) obtained MCIDs for the Constant score, and none of the patients with a graft tear obtained MCIDs in the Constant score (P = .047). CONCLUSION: The graft complete healing rate was 66.7%, although pain relief and functional improvement were satisfactory regardless of graft structural integrity. However, muscle strength recovery was not optimal until 1 year after surgery. LEVEL OF EVIDENCE: Level IV; case series.

Tear pattern after superior capsular reconstruction using an acellular dermal matrix allograft.

BACKGROUND: The healing rate and tear pattern of grafts in superior capsular reconstruction (SCR) using acellular dermal matrix (ADM) allograft are poorly understood, and clinical results based on the graft status remain controversial. METHODS: Fifty-one consecutive patients undergoing arthroscopic SCR with ADM between October 2017 and February 2020 were enrolled. Range of motion, strength, and the visual analog scale pain (PVAS) score, American Shoulder and Elbow Surgeons (ASES) score, and Constant score were evaluated preoperatively and at the last follow-up. Postoperative magnetic resonance imaging was performed in all patients and was obtained at least 6 months (mean, 8.9 ± 3.6 months) after surgery. The graft tear status was analyzed on magnetic resonance imaging, and the numbers of patients who achieved the minimal clinically important difference and patient acceptable symptomatic state were analyzed to determine the differences in outcome according to graft tear status. RESULTS: The range of motion and clinical results improved at a minimum of 1 year (mean, 18 ± 5.4 months), whereas strength in forward flexion and external rotation did not (P = .676 and P = .995, respectively). The graft was intact in 36 of 51 patients (70.6%), 9 patients (17.6%) showed an incomplete graft tear with maintained continuity (partial graft rupture at 1 anchor on either the glenoid or humeral side), and 6 patients (11.8%) showed complete graft rupture (5 on the glenoid side and 1 on the humeral side). In cases with a tear (either incomplete or complete), the odds of achieving the minimal clinically important difference for the PVAS score (P = .047) and ASES score (P = .020) was significantly lower than that of the intact graft. However, when the continuity of the graft was maintained, even in cases with a partial tear, patients who reached the patient acceptable symptomatic state showed significantly higher odds for the PVAS score and trends for the ASES score. CONCLUSION: After SCR using ADM, the graft status could be classified as intact, an incomplete graft tear (where the continuity between the glenoid and humerus was maintained), or an complete tear. When the graft continuity was maintained, even in incomplete graft tears, patients were generally satisfied with postoperative pain and function at 1 year following SCR.

Comparison between anterior and posterior plating systems in extra-articular distal-third diaphyseal humeral fractures.

PURPOSE: The ideal surgical treatment of extra-articular distal-third diaphyseal humeral fractures is controversial in terms of the surgical approach and plate position. The aim of this study was to compare the clinical and radiological outcomes between anterior and posterior plating methods for extra-articular distal-third diaphyseal humeral fractures. METHODS: Twenty-four patients were treated with anterior plating with modified placement of the proximal humeral internal locking system (PHILOS) plate, and 22 patients were treated with posterior plating of the extra-articular distal humerus plate (EADHP). Patient demographics, the fracture configuration, the number of screws in the distal fragment, the operation time, and the time to union were analyzed. The range of elbow motion, Mayo elbow performance score (MEPS), plate-related symptoms, and complications were evaluated at the final follow-up. RESULTS: There were no statistically significant differences in the demographic data between the two groups. The mean operation time for anterior plating (108.2 ± 24.5 min) was significantly shorter than that for posterior plating (144.2 ± 29.5 minutes, p < 0.001). The average number of screws used in the distal humeral fragment was significantly higher with anterior plating (5.7 ± 0.7) than with posterior plating (4.8 ± 0.5, p < 0.001). No patients in the anterior plating group had plate-related symptoms, while 17 patients in the posterior plating group (77%) had discomfort or cosmetic problems related to the plate (p < 0.001). Plate removal was performed upon patient request in nine patients of the posterior plating (52.9%) and four (17%) in anterior plating (p = 0.040). Nonunion occurred in one patient who underwent anterior plating, and one patient who underwent posterior plating had post-operative radial nerve palsy. There were no significant differences in the MEPS or elbow range of motion between the two surgical methods. CONCLUSION: Both anterior and posterior plating provide satisfactory clinical and radiologic outcomes for extra-articular distal-third diaphyseal humeral fractures. Despite the satisfactory outcomes, however, posterior plating is highly associated with plate-related complaints, which might be one of the considerations when the surgical method is selected for extra-articular distal-third diaphyseal humeral fractures.

Clinical differences between patients with early and late revision surgery for symptomatic failed arthroscopic rotator cuff repair.

PURPOSE: Time ranges of revision rotator cuff surgeries after arthroscopic repair are highly variable. However, the cause and clinical relevance of the different timings of revision surgeries have not been analyzed. The purpose of this study was to evaluate the clinical manifestations of patients who required revision surgeries at early and late periods after failed arthroscopic rotator cuff repair, and to identify clinical and radiological differences related to the timing of revision surgery. METHODS: Sixty patients who underwent revision surgery due to symptomatic failed rotator cuff repair after arthroscopic repair were included. Patients were divided into two groups: patients who underwent revision surgeries within 1 year postoperatively (21 patients, group I) and patients who underwent revision surgeries more than 1 year postoperatively (39 patients, group II). Clinical and radiological characteristics were compared between the two groups before primary and revision surgery. RESULTS: VAS for pain (5.9 ± 1.9 in group I, 3.9 ± 1.4 in group II, P < 0.001) and Constant score (50.7 ± 9.9 in group I, 60.4 ± 8.9 in group II, P < 0.001) at the time of revision surgery were significantly different between the two groups. In group II, isometric muscle strength of forward flexion (74.1 ± 21.1 to 63.9 ± 15.1, P = 0.020) and external rotation (73.0 ± 23.5 to 61.2 ± 15.0, P = 0.032) were significantly deteriorated after primary surgery, even with significant improvement of pain and shoulder function (VAS: 5.7 ± 1.9 to 3.9 ± 1.4, P < 0.001; Constant score: 50.3 ± 11.0 to 60.4 ± 8.9, P < 0.001). On postoperative MRI, re-tear at the tendon-bone interface on the greater tuberosity occurred significantly more in group I (81.0%) than group II (51.3%, P = 0.024). Incidence of full-thickness tear of the subscapularis tendon was significantly different between the two groups (42.9% in group I, 12.8% in group II, P = 0.012). CONCLUSION: Patients who had early revision surgeries had significantly worse clinical outcomes after primary surgery than patients who had late revision surgeries. Healing failure at the tendon-bone interface on the greater tuberosity and re-tear combined with full-thickness tear of subscapularis tendon were related to early revision. Conversely, patients of the late revision group had muscle weakness that considerably impacted daily activities, even with improved pain and shoulder function. LEVEL OF EVIDENCE: III.

Early restoration of shoulder function in patients with the Grammont prosthesis compared to lateralized humeral design in reverse shoulder arthroplasty.

BACKGROUND: This study aimed to compare the clinical outcomes and radiographic parameters of patients after reverse shoulder arthroplasty (RSA) between the Grammont prosthesis and lateralized humeral design prosthesis. METHODS: A total of 114 patients who underwent RSA with a lateralized humeral design (group L; 71 shoulders) and medialized humeral design (group M; 43 shoulders) prosthesis for cuff tear arthropathy or irreparable rotator cuff tear were enrolled. Clinical outcomes including visual analog scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores and range of motion (ROM) were serially followed up at postoperative 3, 6, 12, and 24 months. Radiographic parameters were measured to evaluate preoperative and postoperative status. RESULTS: Both prostheses demonstrated similar clinical outcomes and shoulder function preoperatively and at postoperative 2 years (P >.05). However, patients in group M had significantly better postoperative active forward flexion (postoperative 3 months, 115° ± 12° vs. 101° ± 14°; P <.001; 6 months, 125° ± 13° vs. 118° ± 13°; P <.013) and abduction (3 months, 105° ± 12° vs. 98° ± 12°; P = .002); VAS (3 months, 3.1 ± 1.2 vs. 3.7 ± 1.4; P = .031; 6 months, 2.3 ± 1.1 vs. 2.8 ± 1.3; P = .038); ASES (3 months, 64.2 ± 7.0 vs. 60.4 ± 9.2; P = .022; 6 months, 70.6 ± 6.0 vs. 66.6 ± 8.1; P = .007); and Constant scores (6 months, 59.6 ± 6.9 vs. 55.7 ± 9.3; P = .020). Group L showed a significantly lower rate of scapular notching than group M (15.5% vs. 41.8%; P < .001). The position of the proximal humerus in group L was more lateralized and less distalized than in group M after RSA. CONCLUSIONS: RSA with both the Grammont and lateralized humeral design prostheses provided similar shoulder ROM restoration and functional improvements at a minimum of 2 years. However, patients with a humeral lateralized prosthesis showed slower recovery of shoulder function and ROM up to postoperative 6 months despite a lower incidence of scapular notching.

Factors Related to Symptomatic Failed Rotator Cuff Repair Leading to Revision Surgeries After Primary Arthroscopic Surgery.

PURPOSE: To evaluate the clinical characteristics of patients with symptomatic failed rotator cuff repair who required revision surgeries and to identify clinical and radiologic factors related to the need for revision surgery. METHODS: Ninety-eight patients who were diagnosed with rotator cuff retear within 2 years after primary arthroscopic surgery were included. Patients were divided into 2 groups: patients who underwent revision surgery within 2 years postoperatively (44 patients, group I) and patients who did not require additional treatment due to minimal discomfort during the same period (54 patients, group II). Demographic and radiographic factors related to cuff healing were analyzed. Univariate and multivariate analyses were performed to evaluate factors related to revision surgery. RESULTS: Group I showed significantly inferior clinical outcomes at the time of revision compared to group II (American Shoulder and Elbow Surgeons score; 54.0 ± 12.1 vs 86.5 ± 12.2, Constant score; 65.2 ± 10.8 vs 84.0 ± 11.4, P < .001). Total cholesterol level (210.2 ± 40.0 vs 189.7 ± 39.1, P = .012), low-density lipoprotein level (130.7 ± 28.7 vs 115.5 ± 26.9, P = .008), and fatty infiltration of the infraspinatus (20.5% vs 3.7%, P = .011) were significantly greater in group I than in group II. On postoperative magnetic resonance imaging, retear of the infraspinatus tendon occurred significantly more frequently in group I (81.8%) than in group II (37.0%, P < .001). In group I, relative changes in anteroposterior (AP) (19.2 ± 37.8) and mediolateral retear size (29.6 ± 90.7) were significantly greater than in group II (AP; -39.5 ± 19.2, mediolateral; -29.2 ± 26.8, P < .001). Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair (odds ratio 1.19, confidence interval 1.08-1.31, P < .001). CONCLUSIONS: Preoperative serum total cholesterol level, low-density lipoprotein levels, and fatty infiltration of the infraspinatus were significantly related to symptomatic failed rotator cuff repair. Relative change in AP retear size was the most powerful independent predictor of symptomatic failed rotator cuff repair. LEVEL OF EVIDENCE: Level III, Case-control study.

Preoperative Diagnostic Rates and Clinical Outcomes After Arthroscopic Stabilization Procedures for Panlabral Tear of the Glenohumeral Joint.

PURPOSE: To evaluate preoperative diagnostic rates for panlabral tear using imaging studies or physical examinations and to evaluate clinical outcomes after arthroscopic stabilization procedures with 2 different patient surgical positions. METHODS: Patients who underwent arthroscopic stabilization for recurrent anterior shoulder instability with panlabral tear and were followed up for at least 2 years were included. A panlabral tear was defined as labral tear involving at least 270° of the glenoid surface on arthroscopic examination. All patients underwent preoperative magnetic resonance (MR) imaging or MR arthrography and physical examinations including anterior apprehension, posterior jerk, and compressive rotation tests. The clinical outcomes were assessed by the American Shoulder and Elbow Surgeons, Rowe, and visual analog scale for pain scores, and recurrence rate. According to patient position during surgery, patients were divided into group I (beach chair position) and group II (lateral decubitus position). RESULTS: Forty-eight patients (24 in group I and 24 in group II) were enrolled. Preoperative MR imaging or MR arthrography detected only 18.8% of panlabral tears. No patient had positive findings on all 3 physical examination tests for panlabral tear. Clinical outcomes were significantly improved after operation (American Shoulder and Elbow Surgeons score: 58.4 ± 6.2 preoperatively, 85.2 ± 6.4 at the final, P < .001; Rowe score: 49.0 ± 12.2 preoperatively, 86.8 ± 9.1 at the final, P < .001) and postoperative recurrence was occurred in 1patient (2%). No differences were found in clinical outcomes and recurrence rate (4% vs 0%) according to patient positioning, despite the larger number of suture anchors used in group II (6.2 ± 1.5 in group I, 7.6 ± 1.1 in group II, P < .001). CONCLUSIONS: It remained difficult to preoperatively diagnose panlabral tear using standard physical examinations and imaging studies. Nevertheless, arthroscopic stabilization procedures for patients with panlabral tear provided satisfactory clinical outcomes with a low recurrence rate. Patient position during surgery did not alter clinical outcomes and recurrence rate, despite the use of different numbers of suture anchors. LEVEL OF EVIDENCE: Level III, Retrospective comparative therapeutic trial.

A Comparison of Open-Construct PEEK Suture Anchor and Non-Vented Biocomposite Suture Anchor in Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Trial.

PURPOSE: To compare radiologic bone ingrowth and the clinical outcomes of an open-construct (PEEK) (polyether ether ketone) suture anchor with those of a non-vented biocomposite suture anchor in patients with arthroscopic rotator cuff repair. METHODS: Sixty-nine patients were randomly allocated into 2 groups based on type of suture anchors used for rotator cuff repair; group 1: open-construct PEEK anchor (36 patients), group 2: non-vented biocomposite anchor (33 patients). The status of bone ingrowth into the anchor and the presence of cyst formation were evaluated at 6 months postoperatively by computed tomography scan using the Modified Barber's ossification scale. The American Shoulder and Elbow Surgeons score, Constant score, and visual analog scale score for pain and range of motion were evaluated. Magnetic resonance imaging or ultrasonography was performed at 12 months postoperatively to examine the integrity of the repaired rotator cuff tendon. RESULTS: Significant improvements in shoulder function and pain relief were observed regardless of the anchor used (both Group 1 and 2; P < .001). No differences were found in functional scores and range of motion between the 2 groups. Group 1 showed better bone ingrowth grades than group 2 (poor 2.8 vs 24.2%, fair 27.8 vs 39.4%, good 38.9 vs 33.3%, and excellent 30.6 vs 3.0%; P < .001). The rate of cyst formation around the anchor on the 6 months' postoperative computed tomography (group 1: 14% and group 2: 12%) and re-tear rate at 12 months (5% each) showed no difference between the 2 groups. CONCLUSIONS: Shoulder function was improved after complete rotator cuff repair and similar clinical outcomes were achieved regardless of suture anchor material and shape. However, the open-construct PEEK anchor provided better bone ingrowth into the anchor than the non-vented biocomposite anchor at 6 months after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level I; Prospective Randomized Trial.

Effect of tranexamic acid on blood loss after reverse total shoulder arthroplasty according to the administration method: a prospective, multicenter, randomized, controlled study.

BACKGROUND: The ideal method of administering tranexamic acid (TXA) for reverse total shoulder arthroplasty (RTSA) remains unknown. We aimed to evaluate TXA efficacy according to 3 administration methods after RTSA. METHODS: Overall, 102 patients who underwent RTSA using a single implant between September 2016 and November 2018 were randomized to the following groups according to the TXA administration method: intravenous (n = 34; 1 g + 0.9% normal saline 100 mL), topical (n = 33; 2 g + 0.9% normal saline 50 mL), and combined groups (n = 34). Patients were enrolled in 4 tertial referral hospitals for prospective multicenter studies. The primary outcome was a hemoglobin decrease in 24 hours postoperatively; secondary outcomes were total drain volume, transfusion rate, and calculated total blood loss. RESULTS: Demographic data, including preoperative hemoglobin levels, were not different among the 3 groups, but the average age was higher in the combined group (P = .038). Hemoglobin decrease (1.8 ± 1.1 vs. 1.8 ± 1.0 vs. 2.0 ± 1.1 g/dL, P = .769), total drain volume (209.2 ± 147.6 vs. 167.2 ± 102.0 vs. 166.0 ± 118.7, P = .270), and total blood loss (701.1 ± 352.3 vs. 656.5 ± 285.6 vs. 699.0 ± 248.7 mL, P = .810) were not significantly different among the 3 groups (all P > .05). The transfusion rate was higher in the intravenous group (n = 4), whereas only 1 patient had transfusion in the topical group and none in the combined group, although the difference was not statistically significant (P = .084). CONCLUSION: Blood loss did not differ among TXA administration methods after RTSA. However, considering the risk of complication in intravenous TXA, topical TXA after RTSA may be safer, even for patients with normal risk for venous thromboembolic complication.

Minimal Clinically Important Differences and Correlating Factors for the Rowe Score and the American Shoulder and Elbow Surgeons Score After Arthroscopic Stabilization Surgery for Anterior Shoulder Instability.

PURPOSE: To determine the minimal clinically important differences (MCIDs) for the Rowe score and the American Shoulder and Elbow Surgeons (ASES) score after arthroscopic stabilization surgery for anterior shoulder instability and to evaluate the effect of various patient- and treatment-related factors on MCIDs. METHODS: The study enrolled 216 patients who underwent arthroscopic stabilization surgery for anterior shoulder instability. The patients were categorized into "no-change" and "minimal-change" groups by a 15-item questionnaire at the 1-year postoperative visit. The Rowe and ASES scores were assessed preoperatively and at the 1-year postoperative follow-up visit. MCIDs were calculated using an anchor-based method. Correlations between MCIDs and several factors were evaluated using Spearman correlation analysis and univariate regression analysis. RESULTS: On the basis of the questionnaires administered at the 1-year postoperative follow-up visit, 10 patients were assigned to the no-change group and 33 patients were placed in the minimal-change group. MCIDs for the Rowe and ASES scores were 9.7 and 8.5, respectively. Body mass index was negatively correlated with the MCID for the Rowe score (P = .01). Number of dislocations, symptom duration, and presence of Hill-Sachs lesions were positively correlated with the MCID for the ASES score (P = .02, P = .04, and P = .02, respectively). Other variables such as age, sex, and arm dominance were not related to the MCIDs for either the Rowe or ASES score. CONCLUSIONS: In patients who underwent arthroscopic stabilization surgery, differences of at least 9.7 in the Rowe score and 8.5 in the ASES score were clinically relevant. Patients with a greater body mass index required a smaller change in the Rowe score and patients with a greater number of dislocations, a longer symptom duration, or a Hill-Sachs lesion required a larger change in the ASES score to feel clinically relevant changes. LEVEL OF EVIDENCE: Level IV, case series.