Outcomes of arthroscopic single-row repair alone vs. repair with human dermal allograft patch augmentation in patients with large to massive, posterosuperior rotator cuff tears: a retrospective comparative study.

BACKGROUND: Large to massive rotator cuff tears (RCTs) affect shoulder functions profoundly with unmanageable disability without intervention. The retear rates with arthroscopic rotator cuff repair (ARCR) in these patients are abysmal. Patch augmentation has been credited for preventing retears, improving functions by increasing the strength, and acting as a bioconductive scaffold. This study aimed to assess the retear rates and compare the clinical and radiological outcomes between the ARCR with and without acellular human dermal allograft (HDA) augmentation. METHODS: This is a retrospective comparative study among patients diagnosed with large to massive, posterosuperior RCTs, operated between January 2020 and December 2021, including 36 patients (group I) with and 131 patients (group II) without HDA augmentation, with a mean follow-up of 20 (range, 12-35) months. The average age was 64 (range, 49-80) and 66 (range, 41-81) years in groups I and II, respectively. In group I, there were 16 male and 20 female patients, whereas in group II, there were 58 male and 73 female patients. RESULTS: The visual analog scale score improved to 1.1 ± 1.7 in group I and 2.1 ± 1.7 in group II (P = .005). There was a greater improvement in the University of California, Los Angeles shoulder score to 30.1 ± 4.2 in group I compared with 23.2 ± 3.9 in group II (P = .046). Forward flexion (degrees) improved from a mean of 103.2 ± 18.6 to 138.9 ± 23.5 in group I and from 106.4 ± 21.3 to 127.0 ± 19.5 in group II (P = .004). The acromiohumeral interval (mm) measured in anteroposterior radiographs increased to 8.4 ± 1.8 in group I and 8.2 ± 2.0 in group II (P = .006). The satisfaction after the procedure was 4.4 ± 0.6 in group I and 3.1 ± 1.1 in group II (P = .044). The retear rate in the HDA-augmented group was 5.6% as compared with 29.1% in the nonaugmented group, which was statistically significant (P = .007). There were no complications or adverse tissue reactions against HDA seen in any patients. CONCLUSION: In patients with large to massive, posterosuperior RCTs, patch augmentation with acellular HDA significantly averted the retears after ARCR without any graft-related complications. The augmentation also resulted in improved shoulder function and greater range of motion compared with the nonaugmented group.

Does timing influence rehabilitation outcomes in arthroscopic rotator cuff repair with biceps rerouting? a prospective randomized study.

BACKGROUND: Arthroscopic rotator cuff repair with biceps rerouting (ABR) has emerged as a reliable option for treating large posterosuperior rotator cuff tears (RCTs). This study aims to compare functional and structural outcomes of early vs. delayed motion rehabilitation protocols following ABR. METHODS: A total of 101 patients with semirigid, large, posterosuperior RCTs undergoing ABR were randomized into 2 groups: group I (early motion) with 53 patients (34 females, 19 males) and group II (delayed motion) with 48 patients (31 females, 17 males). In group I, the mean age was 63.9 years (range, 46-79), and in group II, it was 65.4 years (range, 43-78). The mean follow-up periods for group I and group II were 16.2 and 15.5 months, respectively. Preoperative and postoperative assessments were conducted at 3, 6, and 12 months, with structural integrity assessed with magnetic resonance imaging at a minimum follow-up of 12 months. Statistical analyses were performed to compare outcomes between the 2 groups. RESULTS: Both groups demonstrated significant improvements in visual analog scale score (group I: 4.0-1.6, group II: 3.7-1.4, P = .501), University of California-Los Angeles shoulder score (group I: 21.5-31.4, group II: 22.4-30.6, P = .331), and acromiohumeral interval (group I: 8.2 mm-9.1 mm, group II: 8.6 mm-9.5 mm, P = .412), with no statistically or clinically meaningful differences. Active range of movements (ROM) were not significantly different between groups, except for active forward flexion at 3 months (group I: 140.1°, group II: 119.2°, P = .006), that was not shown to be translated clinically into differences in function or healing between the groups in this study. Notably, retear rates were similar between groups (group I: 22.6%, group II: 20.8%, P = .826). CONCLUSION: This study's findings reveal no clinically discernible differences in active range of motion at 1-year follow-up between patients who underwent ABR for semirigid, large, posterosuperior RCTs and were assigned to either early or delayed motion protocols. Notably, the early motion group demonstrated a plateau in maximum range of movement improvement as early as 3 months postsurgery. Based on these results, implementing an early motion protocol is recommended as an effective approach in the postoperative rehabilitation following ABR.

Rotator cuff repairs with all-suture tape anchors: no difference in outcomes between with or without all-suture tape anchors.

PURPOSE: This study aimed at comparing the outcomes of medium- to large-sized rotator cuff repairs performed using the suture bridge technique either with or without tape-like sutures, and single row techniques with conventional sutures. METHODS: A total of 135 eligible patients with medium to large rotator cuff tears were identified and analyzed retrospectively, from 2017 to 2019. Only repairs using all-suture anchors were included in the study. Patients were divided into the following three groups: single-row (SR) repair (N = 50), standard double-row suture bridge (DRSB) repair with conventional sutures (N = 35), and DRSB with tape-like sutures (N = 50). The average postoperative follow-up period was 26.3 ± 9.8 months (range, 18-37). RESULTS: DRSB with tapes had the highest re-tear rate of 16% (8/50), but there was no significant difference with the re-tear rates observed in SR (8%, 4/50) and DRSB with conventional sutures (11.4%, 4/35) (n.s.). DRSB with tapes demonstrated higher rate of type 2 re-tears (10%) compared to type 1 re-tears (6%), but the other two groups showed either similar or higher rates of type 1 re-tears compared to that of type 2. Post-operative functional scores of the three groups improved significantly (all p < 0.05), but the differences between the groups were not statistically significant. CONCLUSIONS: No clinical difference in functional outcomes and re-tear rates were observed in DRSB with tapes when compared with SR and DRSB using the conventional sutures. Tape-like DRSB suture which was expected to be superior by its biomechanical advantage was clinically non-superior to conventional DRSB suture. There were no significant differences in VAS scores and UCLA scores. LEVEL OF EVIDENCE: Level III.

Anterior capsular reconstruction in irreparable subscapularis tear: human dermal allograft.

BACKGROUND: The irreparable subscapularis (SSc) tears pose an extremely difficult situation to manage, especially in the younger population. The anterior capsular reconstruction (ACR) with human dermal allograft (HDA) is an alternative to tendon transfer with sound biomechanical advantages and clinical outcomes. The purpose of this study was to evaluate the early clinical and radiologic outcomes of open ACR with HDA in patients with irreparable SSc tears. METHODS: Eighteen patients who had an open ACR with HDA for irreparable SSc tears between August 2020 and January 2022 were enrolled. There were 11 male and 7 female patients with a mean age of 63.7 years and a mean follow-up of 17 months (range, 12-28 months). The dominant side was affected in 10 patients. One of the 18 patients had reconstruction with single-layer HDA, 14 had double-layer HDA, and 3 had SSc augmentation over double-layer HDA. Clinical and radiologic outcomes were assessed and compared pre- and postoperatively. RESULTS: There was significant improvement in visual analog scale score from 6.6 ± 1.6 to 1.6 ± 1.5 (P < .001) and in the total University of California-Los Angeles shoulder score from 12.4 ± 4.3 to 29.0 ± 4.5 (P < .001). Forward flexion, abduction, and internal rotation (IR) increased by 28.6°, 32.5°, and 11.8°, respectively (P < .001). External rotation decreased by 6.4° (P = .020). There was notable improvement in IR strength (percentage of that of the opposite, normal side) from 66.0% ± 19.4% to 84.4% ± 22.3% (P = .008). The mean postoperative coracohumeral distance improved from 3.0 to 6.0 mm (P < .001), the anterior translation of the humeral head reduced from 1.5 to 0.5 mm (P = .210), and the acromiohumeral interval from 8.1 to 8.8 mm (P = .070). The patients' satisfaction at final follow-up was rated 4.1 of 5.0 (P < .001). Sixteen of 18 patients (88.9%) had the HDA healed at the glenoid and humeral side, and 2 (11.1%) had retear at the final follow-up. Among the 17 who had double-layer HDA, none showed any healing between the layers. CONCLUSION: This study showed that early significant and comprehensive improvement inclusive of pain relief, improvement in range of motion, IR strength, and reduction of anterosuperior translation was achievable by open ACR with HDA for irreparable SSc tear.

Long-term outcomes after humeral head replacement and total shoulder replacement for osteonecrosis of the humeral head: a mean follow-up of 8 years.

INTRODUCTION: The purpose of this study was to compare the outcomes and complications after humeral head replacement (HHR) and total shoulder replacement (TSR) in patients with osteonecrosis of the humeral head (ONHH). MATERIALS AND METHODS: Twenty-six patients who underwent shoulder replacement (13 HHRs and 13 TSRs) for nontraumatic ONHH were included. The mean follow-up period was 96.4 months. The visual analog scale (VAS) pain score, the University of California at Los Angeles (UCLA) score, the American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM) at the final follow-up evaluation were used for the assessment of clinical outcomes. RESULTS: The mean VAS pain score, UCLA score, and ASES score showed significant improvement from 6.3, 11.6, and 35.0 before surgery to 2.2, 28.9, and 82.6 at the final follow-up evaluation (all p < 0.001). No significant differences regarding all clinical scores and ROMs were observed between the HHR group and the TSR group, except that a greater abduction angle was observed in the HHR group compared with the TSR group (123.1° versus 96.9°, p = 0.014). Two patients in the TSR group underwent multiple reoperations due to periprosthetic joint infection. No revision surgeries were performed for glenoid erosion following HHR or aseptic glenoid loosening following TSR. CONCLUSIONS: The findings of this study showed satisfactory clinical and radiological outcomes with implant longevity for both HHR and TSR in patients with nontraumatic ONHH. The HHR group had a greater abduction angle compared with the TSR group.

The scissors sign: a provocative test for detecting the leading-edge tear of subscapularis tendon: a diagnostic study.

BACKGROUND: Several physical examination tests and signs have been described to aid in the diagnosis of subscapularis (SSC) tear, but have limitations and variable sensitivity. This study aimed to introduce a novel test for detecting a leading-edge tear of the subscapularis (LETS), the most important tendinous portion of SSC. METHODS: A total of 233 patients who underwent arthroscopic repair for anterior and superior cuff tears between January 2018 to September 2019 were retrospectively reviewed. The provocative test we have coined as the "scissors sign" and the other related clinical tests (i.e., belly press, belly off, Napoleon, lift off, internal rotation lag, bear hug tests) were performed preoperatively. Whether the patient has a LETS or the complete tear of the SSC (CTS) was confirmed by arthroscopic findings. Sensitivity, specificity, and areas under the receiver operating characteristic curve were calculated for each test. RESULTS: In patients who had LETS with or without supraspinatus tear, the scissors sign showed the highest sensitivity (91.4%) with a specificity of 81.6%, positive predictive value (PPV) of 80.2%, and negative predictive value (NPV) of 92.1%. In patients with isolated LETS, the scissors sign also showed the highest sensitivity (90.3%) with a specificity of 81.6%, PPV of 57.1%, and NPV of 96.8%. The scissors sign for the complete tear of the subscapularis (CTS) with or without supraspinatus tear and the isolated CTS had a sensitivity of 73.1 and 75%, respectively. CONCLUSIONS: The scissors sign is a novel provocative test that can be helpful in the diagnosis of subscapularis tears, especially LETS, with its high sensitivity and diagnostic accuracy. In combination with other tests, the scissors sign will be a good screening tool.

Medialized vs. lateralized humeral implant in reverse total shoulder arthroplasty: the comparison of outcomes in pseudoparalysis with massive rotator cuff tear.

BACKGROUND: With the increasing use of lateralized humeral implants in reverse total shoulder arthroplasty (RTSA), it is still unclear whether this design will be as advantageous as the medialized humeral implants in the setting of pseudoparalysis (PP). METHODS: A total of 51 eligible RTSA cases for PP signs due to massive rotator cuff deficiency were selected for the retrospective review. Twenty-five patients were allocated to group L in which the isolated humeral side lateralization was performed (neck-shaft angle of 145°), and 26 patients were allocated to group M (neck-shaft angle of 155°). Pre- and postoperative radiologic measurements including critical shoulder angle, acromiohumeral distance (AHD), lateral humeral offset (LHO), and deltoid wrapping offset (DWO), as well as range of motion (ROM) and clinical outcome scores, were compared. The mean age was 71.0 ± 6.5 years for group L and 70.3 ± 7.0 years for group M, and the overall mean follow-up period was 49.0 ± 13.5 months (range, 25.7-68.9). RESULTS: The preoperative radiologic measurements were similar, but the postoperative LHO and DWO were significantly larger for group L, whereas the postoperative AHD was larger for group M compared with group L, with the values being 39.8 ± 9.7 mm and 33.6 ± 10.4 mm, respectively (P = .034). For the ROM, active forward elevation did improve significantly for both, starting preoperatively with the active ranges of 39° ± 19° (passively 153° ± 24°) for group L and 42° ± 18° (passively 156° ± 11°) for group M-the final postoperative active ranges being 142° ± 16° and 133° ± 33°, respectively, without significant difference between the groups (P = .426). The postoperative recovery of PP for group L was 100% (25 of 25), whereas for group M, it was 96.2% (25 of 26). The final visual analog scale (VAS) scores and University of California Los Angeles (UCLA) shoulder scores improved significantly for both groups, but the differences between the groups at the final assessments were insignificant. The 4 complications were periprosthetic fracture, acromial stress fracture, periprosthetic joint infection, and neuropraxia, all of which were in group M, and scapular notching with higher grades were more prevalent for group M (26.9%, 7 of 26). CONCLUSIONS: With RTSA, good outcomes and recovery were achieved in most cases of PP. The postoperative active elevation range and functional outcomes were not affected by medialization or lateralization of the humeral implant. Earlier recovery of motion was observed with the lateralized group, but no significant differences were seen in the final ROM between the groups.

Assessment of postoperative acromial and subacromial morphology after arthroscopic acromioplasty using magnetic resonance imaging.

OBJECTIVE: To identify the morphological characteristics of the acromion and subacromial bursal space after arthroscopic acromioplasty using magnetic resonance imaging (MRI). MATERIALS AND METHODS: One hundred patients who received arthroscopic rotator cuff repair and acromioplasty each received at least three MRI examinations (preoperative, first immediate postoperative, and second follow-up imaging between 8 months and 1 year postoperatively). Changes over time in the thickness and morphology of the postoperative acromion as well as the subacromial bursal space were assessed. Clinical and radiological parameters were also analyzed to identify any association with changes in acromial morphology. RESULTS: Despite minimal acromial thinning observed at the first immediate postoperative state, the acromions showed significant thinning at the second postoperative MRI, with a mean reduction of 32%. Along with acromial thinning, an exaggerated concave contour of the acromial undersurface was observed in some patients. In the subacromial space, a loculated fluid collection developed in 91% of the patients at the second postoperative follow-up. No statistically significant association was noted between postoperative acromial thickness change and clinical or radiological factors (P value > 0.05). CONCLUSION: A significant delayed reduction in acromial thickness within approximately 1 year of arthroscopic acromioplasty is thought to be a normal postoperative feature. The simultaneous collection of a loculated, cyst-like fluid in the subacromial bursal space may be an important associated factor of postoperative acromial thinning.

Biceps Rerouting for Semirigid Large-to-Massive Rotator Cuff Tears.

PURPOSE: To compare clinical and radiographic results of arthroscopic rotator cuff repair (ARCR) with biceps rerouting (BR) and those of conventional repair for semirigid, large-to-massive rotator cuff tear. METHODS: We prospectively collected data of 111 patients who underwent either ARCR + BR (n = 59, group 1) or only ARCR (n = 52, group 2) for semirigid, large-to-massive rotator cuff tear between January 2016 and December 2018. We comparatively analyzed both groups with respect to preoperative factors including concomitant lesions of the long head of the biceps tendon (LHBT). Univariate logistic regression analysis was performed to identify predictive variables for occurrence of retear after ARCR + BR. RESULTS: Mean age of groups 1 and 2 were 62.8 and 63.7 years, respectively (P = .484). Mean follow-up period in groups 1 and 2 were 15.1 and 25.1 months, respectively (P = .102). Mean range of motion and functional scores improved significantly (P < .05) and comparably (P > .05) in both groups. In total, 11 (18.6%) and 25 (48.1%) patients from groups 1 and 2, respectively, showed retear of the repaired rotator cuff at final follow-up (P < .01). Of 45 group 1 patients who showed less than 50% partial tearing of the LHBT preoperatively, 6 (13.3%) experienced retear. Comparatively, of 14 patients with partial tearing involving more than 50% of the LHBT, 5 (35.7%) suffered postoperative retear. If the patients had partial tear involving more than 50% of LHBT preoperatively, the odds ratio (OR) to have retear was 4.222 (P = .037). Wider (OR, 1.445, P = .047) and thinner (OR, 0.166, P = .019) LHBT were the prognostic factors to have retear. Three (5.1%) group 1 patients showed the Popeye deformity at final follow-up. CONCLUSIONS: ARCR + BR for semirigid, large-to-massive rotator cuff tears effectively improved clinical and structural outcomes as also shown in the conventional repairs. However, the retear rate was significantly lower in patients who underwent ARCR + BR than those treated conventionally. Partial tearing involving more than 50% of the LHBT and wide and/or thin tendon morphology were significant risk factors for postoperative occurrence of retear. LEVEL OF EVIDENCE: Level III, retrospective therapeutic comparative trial.

Retracted Rotator Cuff Repairs Heal With Disorganized Fibrogenesis Without Affecting Biomechanical Properties: A Comparative Animal Model Study.

PURPOSE: To determine the differences in the scar tissue formation during the healing of the repaired retracted cuff tear from that of the nonretracted tear. METHODS: Eighteen right rabbit shoulders received a 1-cm transverse cuff incision over the footprint to simulate "nonretracted cuff tears" before the transosseous repairs (group A). A 1-cm tendinous portion was excised from 18 left shoulders to create defects to simulate "retracted cuff tears" before repairing the defects (group B). At week 12 postrepair, 20 and 16 shoulders underwent histologic and biomechanical analyses, respectively. Eight shoulders were used as a control group for biomechanical analyses. RESULTS: All specimens showed good healing and continuity of the repaired tendons. At low magnification, fibrous tissue firmly held the tendon-to-bone junctions in group A; however, all specimens in group B showed medially retracted tendons with fibrous tissue continuity between the tendon stumps and footprints. At medium magnification, more irregular collagen fiber orientation was observed in group B. Polarized light microscopy showed fibrous tissue continuity with medially retracted tendons in group B. When we quantified collagen fiber orientation using ImageJ software, group B had inferior grayscale measurements when compared with group A (P = .001). At week 12, no statistical differences existed in mean loads-to-failure at the repair sites between the groups (P = .783). CONCLUSIONS: In the nonretracted cuff tears, fibrous tissue bound the tendon-to-bone junction with healing. After the healing of the retracted cuff tears, continuity of nontendinous tissue was observed adjacent to the medially retracted tendon, which comprised more disorganized immature fibrous tissue than that in the nonretracted cuff tears. CLINICAL RELEVANCE: Unlike the healing of nonretracted rotator cuff tear, repairing of the "retracted" tendon end of cuff tear still resulted in retraction of the tendon back to its original position but being held down with fibrous tissue to the footprint.

Hematologic Expression After Shoulder Surgery: Normalization Curve of Serum Inflammatory Markers.

PURPOSE: To determine the normalization curves of the serologic markers including white blood cell (WBC) count, WBC differential for segmented neutrophil (WBC seg.), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) after elective shoulder surgery and to investigate the hematologic differences among different shoulder surgeries. METHODS: Seventy-seven patients underwent arthroscopic rotator cuff repair (RCR, group A), 44 patients had open rotator cuff repair (group B), and 84 patients had shoulder arthroplasty (group C). Peak and normalization times of markers were determined at preoperatively, postoperative day (POD) 1 and 2 days, 1 and 2 weeks, 1, 2, 3, 6 months, and 1 year after surgery. The normal ranges of serologic markers were set to WBC 4000 to10,000/µL, WBC seg. 40% to 60%, ESR 0 to 20 mm/h, and CRP 0 to 0.8 mg/dL. RESULTS: Groups reached peak mean WBC count and WBC seg. on POD 1; mean WBC count started decreasing on POD 2 but was within normal value afterwards. Mean WBC seg. decreased to normal value at 1 month postoperatively in group A and B and at 2 months postoperatively in group C. Mean ESR peaked at 2 weeks postoperatively and normalized after 1 month in groups A and B and 3 months in group C. Mean CRP levels peaked on POD 2 in all groups and normalized within 2 weeks postoperatively in groups A and B and 1 month postoperatively in Group C. Normalized values of WBC count, WBC seg., and ESR varied widely. In contrast, CRP showed a consistent undetectable median, upper and lower quartile values less than 0.5 after normalization. Mean serum ESR and CRP values at peak time were significantly greater in group C than in the other groups (P = .001). CONCLUSIONS: The mean CRP levels were normalized at 2 weeks after rotator cuff repair and at 1 month after arthroplasties. Unlike the other serologic markers, CRP had consistent normalized values of median, upper and lower quartile afterwards. The peak levels of the inflammatory markers were greater and therefore normalized slower following more invasive surgery. LEVEL OF EVIDENCE: Level III, case control study.

Nontendinous healing after repairing of retracted rotator cuff tear: an imaging study.

BACKGROUND: Follow-up magnetic resonance imaging (MRI) after rotator cuff repair can sometimes demonstrate healing with nontendinous tissue that extends from the footprint to the retracted tendon end, which is inferred as fibrous tissue formation. The aim was to investigate this particular finding and its significance. METHODS: There were 494 eligible cases of healed supero-posterior medium-sized to massive rotator cuff repairs, after the exclusion of retears. A retrospective review was performed for the 3 groups that were divided according to their MRI appearances of healing: type I described the direct healing of the tendon to the footprint, whereas type II demonstrated the distinctive continuity of nontendinous tissue from the footprint to the retracted tendinous portion, and type III also showed a similar appearance but with obvious thinning of the tissue, without any evidence of defect confirmed on the routine outpatient ultrasonograph. RESULTS: Only 108 of 494 patients (21.9%) demonstrated type I healing, whereas the signs of nontendinous healing were evident for the rest, with the 116 patients (23.5%) being classified as type III with attenuation. Comparing the preoperative tendon retraction, 34.8% and 37.2% of the Patte stages 2 and 3, respectively, resulted in type III healing, which were significantly higher compared with that of stage 1 (15.3%, P < .001). Type III healing had the highest average preoperative Goutallier grades. The average postoperative visual analog scale and the American Shoulder and Elbow Surgeons (ASES) scores have improved significantly for all 3 groups (P < .05), with the ASES score being 86.1±15.9 for type I, 93.7±36.1 for type II, and 87.8±15.1 for type III without significant differences between the groups (P = .3). CONCLUSIONS: Only a fifth of the rotator cuff repairs led to a direct healing to the footprint, and the rest healed with MRI appearance of nontendinous tissue formation bridging the retracted tendinous portion and the footprint. These MRI appearances did not represent the true tendinous tissue formation between the torn end of the tendon and the bone after healing. Such appearances did not seem to affect the clinical outcomes.

Effects of comorbidities on the outcomes of manipulation under anesthesia for primary stiff shoulder.

BACKGROUND: Studies on the effects of manipulation under anesthesia (MUA) for primary stiff shoulder when different comorbidities are present are lacking. Our aim was to assess how comorbidities influence the recovery speed and clinical outcomes after MUA. METHODS: Between April 2013 and September 2018, 281 consecutive primary stiff shoulders in the frozen phase treated with MUA were included in this study. We investigated the comorbidities of patients and divided them into the control (n = 203), diabetes mellitus (DM) (n = 32), hyperlipidemia (n = 26), and thyroid disorder (n = 20) groups. The range of motion (ROM) and clinical scores for each group before MUA and 1 week, 6 weeks, and 3 months after MUA were comparatively analyzed. We identified the ROM recovery time after MUA and the responsiveness to MUA. Then, subjects were subdivided into early and late recovery groups based on their recovery time and into successful and nonsuccessful MUA groups based on their responsiveness to MUA. RESULTS: Significant improvements in ROM and clinical scores at 3 months after MUA were observed in all groups. Significant differences in ROM among the 4 groups were also observed during follow-up (P < .05). The DM group had significantly lower ROM values, even at 3 months after MUA, compared with the control group. The ROM recovery speed after MUA was slowest in the DM group, followed by the thyroid disorder, hyperlipidemia, and control groups. Most (90.6%) of the DM group experienced late recovery. The proportion of nonsuccessful MUA was higher in the DM and thyroid disorder groups than that in the control and hyperlipidemia groups (P = .004). During follow-up, there were no differences among groups regarding the visual analog scale, University of California at Los Angeles shoulder, and Constant scores. CONCLUSION: The ROM recovery speed and responsiveness to MUA for primary stiff shoulder were poorer for the DM and thyroid disorder groups than for the control group. In particular, compared with any other disease, outcomes were poorer when the comorbidity was DM. If patients have comorbidities, then they should be informed before MUA that the comorbidity could affect the outcomes of treatment.

Incidence and risk factors of acromial fracture following reverse total shoulder arthroplasty.

BACKGROUND: The occurrence and related predictors of acromial fracture following reverse total shoulder arthroplasty (RTSA) have not been fully elucidated. The aim of this study was to determine the incidence and risk factors of acromial fractures after RTSA. METHODS: We conducted a multicenter, retrospective case-control study of 787 cases (29 in acromial fracture group and 758 in control group) that underwent RTSA performed by 6 surgeons. The mean duration of follow-up after RTSA was 31.6 ± 21.8 months (range, 12-136 months). Demographic variables (age, sex, arm dominance, body mass index, working status, bone mineral density [BMD]), clinical variables (preoperative diagnosis, previous operation, implant design, preoperative clinical scores, screw size in glenoid fixation, postoperative rehabilitation), and radiographic variables (acromial thickness, critical shoulder angle, deltoid length, humeral offset to lateral acromion) were investigated. To determine risk correlation, univariate analysis and multivariate logistic regression analysis with calculated odds ratios (ORs) were performed. RESULTS: Postoperative acromial fractures occurred in 29 of the 787 shoulders with RTSA (3.7%). Acromial fractures were detected at a mean of 10.0 months (range, 1-66 months) postoperatively. Univariate analysis revealed that the occurrence of an acromial fracture was significantly associated with a previous operation (38% [11 of 29] vs. 21% [156 of 758], P = .025) and BMD (-2.33 vs. -1.74, P = .013). Multivariate logistic regression analysis found that the occurrence of a postoperative acromial fracture was significantly associated with a previous operation (P = .034; OR, 2.91; 95% confidence interval, 1.08-7.84) and deltoid length (P = .004; OR, 1.04; 95% confidence interval, 1.01-1.07). CONCLUSION: Acromial fracture following RTSA is not an uncommon complication, with an overall incidence of 3.7%. A previous operation, increased deltoid length, and low BMD were risk factors of acromial fracture following RTSA.

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.

Incidence of Cutibacterium acnes from shoulder arthroplasties in Asians: ethnic differences should be considered.

BACKGROUND: Most studies on Cutibacterium acnes in shoulder surgery have been conducted in the Western population, and studies on Asians are rare. We evaluated the incidence and risk factors of C acnes in shoulder arthroplasty in Asians. METHODS: We retrospectively analyzed 154 patients between January 2017 and May 2019 who underwent shoulder arthroplasty. Swabs were taken after skin preparation from the skin surface of the anterior acromion, axilla, and joint fluid to study the incidence of C acnes. Before skin preparation we also collected swabs from the anterior acromion, axilla, and thigh from 59 of the 154 patients. RESULTS: Eight of 154 patients after and 6 of 59 patients before skin preparation were positive for C acnes. C acnes were found in 2 patients at the anterior acromion and in 6 at the synovial joint after skin preparation and in 1 patient at the axilla, in 5 at the anterior acromion, and in 3 at the thigh before preparation. History of steroid injection and number of steroid injections were significantly associated with C acnes isolation (P = .039 and P = .006, respectively), whereas age, sex, body mass index, shoulder surgery history, hypertension, diabetes, and cerebrovascular disease were not, as were serum inflammatory markers, including white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate. CONCLUSION: A total of 5.2% of the patients after skin preparation and 10.2% of patients before skin preparation were found to be positive for C acnes. The incidence of C acnes in patients who underwent shoulder arthroplasties in Asia was low and, thus, ethnic differences should be considered for C acnes. The history and number of steroid injections were associated with isolation of C acnes.

Neurologic deficit after reverse total shoulder arthroplasty: correlation with distalization.

BACKGROUND: Neurologic problems after reverse total shoulder arthroplasty (RTSA) have been reported, but there are a lack of studies regarding which nerve(s) are damaged and the outcomes for the patients who had neurologic complications after RTSA. The purpose of this study was to assess the prevalence and outcomes of neurologic deficit after RTSA and to evaluate the correlation between nonanatomic rearrangement of the shoulder joint and neurologic complications after RTSA. We hypothesized that the neurologic deficit was associated with excessive distalization or lateralization of the humerus after RTSA. METHODS: RTSA was performed on 182 consecutive shoulders with cuff tear arthropathy. Comparative analysis was performed on 34 shoulders with (group 1) and 148 shoulders without (group 2) neurologic deficit. RESULTS: The mean follow-up period in the study was 58.5 months (range: 24-124). The mean age was 71.5 ± 7.7 years in group 1 and 73.1 ± 7.2 years in group 2. Neurologic deficit after RTSA was found in 34 shoulders (19%). The mean postoperative acromiohumeral distance was 34.1 ± 11.0 mm in group 1 and 29.4 ± 7.6 mm in group 2 (P = .015). Significant differences in terms of postoperative distalization of the humerus were seen between group 1 (24.5 ± 9.4 mm) and group 2 (20.5 ± 8.3 mm) (P = .009). The most common forms of neurologic deficit after RTSA were axillary nerve (41.2%) and radial nerve (15%) injuries. Thirty shoulders (88%) had neuropraxia, and 4 shoulders (12%) had axonotmesis. By conservative treatment, all patients with neurologic complications achieved complete recovery without any additional surgery; the mean recovery period was 7.4 months (range: 2-38 months). CONCLUSION: Neurologic deficit occurred in 19% of patients who underwent RTSA, and it was significantly correlated with humeral distalization after surgery. Axillary nerve was mostly involved, and all patients with neurologic deficit achieved complete recovery without any additional surgery.

Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) is a widely accepted treatment for irreparable massive rotator cuff tear (mRCT) and cuff tear arthropathy (CTA), but its impact on activities of daily living (ADLs) remains unclear. METHODS: We retrospectively analyzed 77 patients (age range, 54-87 years; follow-up range, 36.1-120.3 months) with irreparable mRCT and CTA treated by medialized RSA between 2008 and 2015. Ten activities considered essential for daily living were selected and scored from 0 to 3. RESULTS: The mean visual analog scale scores during motion and University of California at Los Angeles and Constant scores significantly improved at final follow-up (all P < .001). Active forward flexion, external rotation at the side, and internal rotation to the posterior (IRp) were 92.5%, 79.6%, and 48.4% of the contralateral side, respectively, at final follow-up. Active forward flexion and external rotation at the side recovered within 6 months after surgery, similar to the level at final follow-up, but IRp did not reach the preoperative status until final follow-up. ADLs with mean scores of less than 2.0 at final follow-up were "wash the opposite shoulder," "wash the opposite axilla," "use a back pocket," "manage the toilet," and "wash the back" (only 36.4% of patients were able to wash their back at final follow-up). CONCLUSIONS: RSA for irreparable mRCT and CTA showed satisfactory clinical outcomes. However, IRp was associated with a limited range compared with the other shoulder motions; therefore, all ADLs associated with internal rotation demonstrated lower recovery rates than expected.

When Do Patients Return to Previous Daily Activity After Arthroscopic Rotator Cuff Repair?

BACKGROUND: One potential advantage of arthroscopic shoulder surgery over open approaches is accelerated recovery; however, the functional recovery period of daily activities for specific movements after arthroscopic rotator cuff repair has not yet been reported, to our knowledge. QUESTIONS/PURPOSES: (1) After arthroscopic rotator cuff repair, when are patients able to perform low-level and high-level front-of-body motion, low-level and high-level behind-the-back motion, strength-related activities, and sports/leisure activities? (2) How do tear size, arm dominance, and retear affect performance of these activities? (3) When does the UCLA score cross above 80% in each UCLA score component (28 points)? METHODS: A 2-year prospective study of 135 patients who underwent arthroscopic rotator cuff repair was performed (45 in small-sized, 45 in medium-sized, and 45 in large-to-massive-sized groups). The mean age was 60 years. Thirty-one and 104 shoulders were nondominant and dominant shoulders, respectively. Twenty-seven shoulders showed retear on MRI taken 9 months after surgery. We evaluated the functional recovery periods using the questionnaire and the UCLA scores and assessed influencing factors such as tear size, arm dominance, and retear. The patients were asked to fill out a questionnaire at 1, 2, 3, 6, 9, 12, 15, 18, and 24 months after surgery. The questionnaire evaluated front-of-the-body, behind-the-back, general, simple strength-related, and sports/leisure activities. Based on the UCLA evaluation, the functional recovery period was defined as the time required to achieve a score > 80% in each UCLA score component. RESULTS: Patients experienced recovery of low-level and high-level ROM front-of-the-body, high-level ROM behind-the-back, simple strength-related, and sports/leisure activities within 2 ± 1, 3 ± 2, 9 ± 0, 10 ± 2, and 14 ± 3 months, respectively, after surgery. Two patients with large-to-massive tears did not gain the recovery of high-level ROM behind-the-back, simple strength-related, and sports/leisure activities. Patients with large-to-massive tears were delayed from some activities compared with patients with small tears (10 ± 0 versus 7 ± 1 for washing back, p = 0.010; 11 ± 0 versus 10 ± 0 for lifting 5 kg, p = 0.020; 15 ± 0 versus 13 ± 0 for sports/leisure). Arm dominance was not associated with functional recovery. Patients with retears, compared with intact healing, had a longer time to return to washing hair (3 ± 2 versus 3 ± 1, p = 0.007), combing (4 ± 3 versus 2 ± 1, p = 0.002), washing the back (10 ± 3 versus 8 ± 3, p = 0.034), and sports/leisure (15 ± 3 versus 14 ± 3, p = 0.010). UCLA score in 134 patients reached 28 points, corresponding to the functional recovery period at 6 ± 3 months. One patient did not reach > 28 points on the UCLA score. CONCLUSIONS: It took patients an average of 14 months to recover their daily motion after surgery. Tear size and retear affected only the recovery period of high-level motion activities and sports/leisure. This study was believed to serve as a guideline to inform patients about functional recovery after arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level III, therapeutic study.

Accuracy of MRI in diagnosing intra-articular pathology of the long head of the biceps tendon: results with a large cohort of patients.

BACKGROUND: It is difficult to diagnose the pathology of the long head of the biceps tendon (LHBT) clinically. This study aimed to determine the diagnostic value of standard non-enhancing magnetic resonance imaging (MRI) for detecting LHBT pathology and identify the most useful diagnostic signs on MRI. METHODS: A total of 554 patients with preoperative 3-Tesla (3 T) MRI who underwent arthroscopic surgery for rotator cuff tears were retrospectively enrolled. Abnormal signs of LHBT on MRI included diameter change, contour irregularity, and alteration of signal intensity. Arthroscopic findings were classified according to tear progress and used as a reference standard: Type I, normal tendon; Type II, hourglass-shaped hypertrophic tendon with fraying extending into the bicipital groove; Type III, partial tear involving less than 50% of tendon width at the intraarticular region without fraying in the bicipital groove; Type IV, partial tear involving more than 50% of tendon width and extending into the bicipital groove; and Type V, complete tear (cutoff) of the tendon. Using receiver operating characteristic, prediction accuracies of MRI findings were assessed compared to those of arthroscopic findings. RESULTS: Arthroscopic findings showed LHBT pathology in 124 (22.4%) cases. High diagnostic efficacy was achieved when 'at least 2 abnormal signs' was set as diagnostic criteria (sensitivity: 77.9%; specificity: 93.7%; positive predictive value: 76.3%). Types II and III lesions showed the highest sensitivities (36.8 and 66.7%, respectively) in abnormal alteration of signal intensity in the parasagittal view while Type IV showed the highest sensitivity (82.3%) in diameter change in axial view. Interobserver agreements were substantial to almost perfect, with kappa value of 0.69-0.81. CONCLUSIONS: The standard non-enhancing 3 T MRI had a high diagnostic value in preoperative detection of LHBT pathology. Its accuracy was increased when diagnostic criterion was set as '2 or more abnormal signs (diameter change, contour irregularity, and alteration of signal intensity)'. The single diagnostic sign with the highest sensitivity was alteration of signal intensity in the parasagittal view.