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Journal of Orthopaedic Science :... Jun 2024The aim of this study was to compare outcomes and complications in patients with and without a history of prior rotator cuff surgery who underwent reverse total shoulder...
Does prior rotator cuff surgery influence the outcomes and complications after reverse total shoulder arthroplasty in patients with cuff tear arthropathy or massive rotator cuff tear? A propensity score-matched study.
BACKGROUND
The aim of this study was to compare outcomes and complications in patients with and without a history of prior rotator cuff surgery who underwent reverse total shoulder arthroplasty (RTSA).
METHODS
Two-hundred and nine consecutive patients who had undergone RTSA for rotator cuff insufficiency with a minimum 12-months follow-up period were reviewed. A total of 35 patients with a history of prior rotator cuff surgery were made the study group (PS group). Using propensity score matching for age and sex, these patients were matched 1:3 with a control group of 105 patients with no history of prior surgery (NPS group). The mean follow-up period was 41.4 months.
RESULTS
Both groups showed a significant improvement of clinical scores and range of motion after RTSA. The PS group showed a significantly higher final visual analog scale (VAS) pain score compared with the NPS group (P = 0.020). The PS group showed a significantly higher incidence of acromial stress fracture compared with the NPS group (17.1% vs 4.8%, P = 0.018), but no significant difference in the overall complication rate was observed (25.7% vs 13.3%, P > 0.05). The PS group showed a significantly higher reoperation rate compared with the NPS group (14.3% vs 1.9%, P = 0.004).
CONCLUSIONS
Our study demonstrated that a history of prior rotator cuff surgery was associated with a high incidence of acromial stress fracture and reoperation after RTSA as well as a high final VAS pain score, although satisfactory clinical outcomes after RTSA were achieved in both groups.
PubMed: 38942650
DOI: 10.1016/j.jos.2024.06.010 -
Journal of Shoulder and Elbow Surgery Jun 2024Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day...
BACKGROUND
Previous studies have demonstrated the safety and cost-effectiveness of outpatient total shoulder arthroplasty (TSA), with the majority of studies focusing on 90-day outcomes and complications. Patient selection algorithms have helped appropriately choose patients for an outpatient TSA setting. This study aimed to determine the outcomes of TSA between outpatient and inpatient cohorts with at least a 2-year follow-up.
METHODS
A retrospective review identified patients older than 18 years who underwent a TSA with a minimum of 2-year follow-up in either an inpatient or outpatient setting. Using a previously published outpatient TSA patient-selection algorithm, patients were allocated into three groups: outpatient, inpatient due to insurance requirements, and inpatient due to not meeting algorithm criteria. Outcomes evaluated included visual analog scale (VAS) pain, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, range of motion (ROM), strength, complications, re-admissions, and re-operations. Analysis was performed between the outpatient and inpatient groups to demonstrate the safety and efficacy of outpatient TSA with midterm follow-up.
RESULTS
A total of 779 TSA were included in this study, allocated into the outpatient (N = 108), inpatient due to insurance (N = 349), and inpatient due to algorithm (N = 322). The average age between these groups was significantly different (59.4 ± 7.4, 66.5 ± 7.5, and 72.5 ± 8.7, respectively; P < 0.0001). All patient groups demonstrated significant improvements in preoperative to final patient-outcomes scores, ROM, and strength. Analysis between cohorts showed similar final follow-up outcome scores, ROM, and strength, with few significant differences that are likely not clinically different, regardless of surgical location, insurance status, or meeting patient-selection algorithm. Complications, reoperations, and readmissions between all three groups were not significantly different.
CONCLUSION
This study reaffirms prior short-term follow-up literature. Transitioning appropriate patients to outpatient TSA results in similar outcomes and complications compared to inpatient cohorts with mid-term follow-up.
PubMed: 38942227
DOI: 10.1016/j.jse.2024.05.012 -
Journal of Shoulder and Elbow Surgery Jun 2024Over-prescription of opioids in the United States increases risks of opioid dependence, overdose, and death. Increased perioperative and postoperative opioid use during...
BACKGROUND
Over-prescription of opioids in the United States increases risks of opioid dependence, overdose, and death. Increased perioperative and postoperative opioid use during orthopedic shoulder surgery is a significant risk factor for long term opioid dependence. The authors hypothesized that a multidisciplinary perioperative pain management program (Transitional Pain Service or TPS) for major shoulder surgery would lead to a reduced amount of opioids required postoperatively.
METHODS
A TPS was implemented at a Veterans Affairs Medical Center focused on non-opioid pain management and cessation support. Opioid consumption during the implementation of the TPS was compared to a historical cohort. All patients undergoing shoulder arthroplasty or rotator cuff repair were included. The primary outcome was the proportion of patients continuing opioid use at 90 days postoperatively. Secondary outcomes included postoperative pain scores, time to opioid cessation, and median opioid tablets consumed at 90-days. A multivariable model was developed to predict total opioid use at 90-days postoperatively. Kaplan Meier curves were calculated for time to opioid cessation.
RESULTS
The TPS group demonstrated decreased persistent opioid use at 90 days post-discharge (12.6% vs. 28.6%; p=0.018). Independent predictors associated with increased total opioid tablet prescriptions at 90 days included length of stay (β=19.17), anxiety diagnosis (β=37.627), and number of tablets prescribed at discharge (β=1.353). Shoulder arthroplasty surgery (TSA) was associated with decreased 90-day opioid utilization (β= -32.535) when compared to cuff repair (RCR). Median time to cessation was shorter in TSA (6 days) when compared with RCR (8 days). Pain scores were reduced compared to population mean by post-discharge day 2 for TSA and by post-discharge day 7 for RCR. Median number of post-discharge opioid tablets (oxycodone 5 mg) consumed under TPS management was 25 in both RCR and TSA surgery groups (180 MME).
DISCUSSION AND CONCLUSIONS
This study demonstrates that a TPS reduces the amount of opioid use of patients undergoing shoulder arthroplasty or cuff repair at 90 days when compared with a historical control. Multivariable regression indicated that fewer opioid tablets at discharge was a modifiable factor that may aid in reducing opioid consumption and that anxiety diagnosis, increased length of stay, and cuff repair surgery were other factors independently associated with increased opioid consumption. This data will assist surgeons in counseling patients, setting narcotic use expectations, and minimizing overprescribing. Use of a similar multidisciplinary perioperative pain management program may greatly reduce opioid over prescriptions nationally.
PubMed: 38942226
DOI: 10.1016/j.jse.2024.05.005 -
Journal of Shoulder and Elbow Surgery Jun 2024Rotator cuff tears (RCTs) are a prevalent cause of shoulder pain and dysfunction. For those who fail initial conservative treatment, operative intervention can be... (Review)
Review
INTRODUCTION
Rotator cuff tears (RCTs) are a prevalent cause of shoulder pain and dysfunction. For those who fail initial conservative treatment, operative intervention can be pursued. A significant and common complication after rotator cuff repair (RCR) is retearing or non-healing. Numerous augmentations to traditional suture RCR have been studied. Of these, the Smith+Nephew Regeneten bioinductive collagen patch has had promising initial results; however, analytic data for its use is lacking, and there is no meta-analysis comparing the available data to historical RCR outcomes.
METHODS
A PRISMA-guided literature search was conducted using Ovid MEDLINE, PubMED, Cochrane, and ClinicalTrials.gov. 13 studies met inclusion and exclusion criteria. Only clinical trials on full and partial-thickness tears were included. American Shoulder and Elbow Surgeon score (ASES), Constant-Murley score (CMS), the visual analog scale for pain (VAS), the minimal clinically important difference (MCID), tendon thickness, and complication rates were primary outcomes of interest. A meta-analysis was performed to determine the overall complication and retear rate from the included studies.
RESULTS
ASES, CMS, and VAS improved significantly in all studies that reported them, and most patients achieved MCID. Patient-reported outcome measure (PROM) improvements were similar to historical improvements in standard RCR, and a similar proportion of patients achieved MCID after standard repair. Tendon thickness improved significantly and to a similar degree as standard RCR. Overall retear rate after full thickness RCR augmented with the bioinductive patch was 8.3%. For partial thickness RCR, total retear rate of 1.1% across all patients. The overall complication rate with the bioinductive patch was 15.5% across all full-thickness RCR studies and 16.2% in partial thickness RCR. We found overall retear rate to be lower after augmentation with the bioinductive patch compared to traditional repair; however, the overall complication rate was similar for full-thickness tears and higher for partial-thickness tears. Lastly, adverse reactions to the bioinductive patch were noted at 0.2%.
CONCLUSIONS
The bioinductive collagen patch appears to be a safe augmentation for rotator cuff repair. Patients are likely to experience significant subjective improvement in PROMs and significant increases in tendon thickness. Retear rate has been a concern after RCR for decades, and the bioinductive patch may help mitigate this risk. There is a lack of case-control studies comparing the bioinductive patch to traditional suture RCR. Such data is needed to better determine the role of the bioinductive patch in the treatment of full and partial-thickness rotator cuff repairs.
PubMed: 38942225
DOI: 10.1016/j.jse.2024.05.002 -
Journal of Shoulder and Elbow Surgery Jun 2024Many distal humerus nonunions are associated with bone loss and rigid internal fixation is difficult to obtain, especially for low transcondylar nonunions and those with...
INTRODUCTION
Many distal humerus nonunions are associated with bone loss and rigid internal fixation is difficult to obtain, especially for low transcondylar nonunions and those with severe intraarticular comminution. The purpose of this study was to analyze the results of a strategy to address this challenge utilizing internal fixation using the Supracondylar Ostectomy + Shortening (i.e. S.O.S.) procedure for distal humerus nonunions. The goals of this procedure are to (1) optimize bony contact and compression through re-shaping the nonunited fragments at the supracondylar level with selective humeral metaphyseal shortening, (2) maximize fixation using parallel-plating, and (3) provide biologic and structural augmentation with bone graft.
MATERIALS AND METHODS
Between 1995 and 2019, 28 distal humerus nonunions underwent internal fixation using the S.O.S. procedure at a single Institution. There were 14 males and 14 females with mean age of 47 (range 14-78) years at the time of the S.O.S procedure and an average of 1.7 prior surgeries. Medical records and radiographs were reviewed to determine rates of union, reoperations, complications, and Mayo Elbow Performance Scores (MEPS). Patients were also prospectively contacted to update their MEPS and gather additional information on complications and reoperations. Mean clinical exam follow-up was 17 months, mean clinical contact follow-up was 19 months, and mean radiographic follow-up was 32 months.
RESULTS
Four patients did not have adequate follow-up to determine union. Of the remaining 24 elbows, 22 achieved union. Two elbows developed collapse of the articular surface and were converted to a total elbow arthroplasty (TEA). There were complications in 10 elbows: contracture (5), superficial infection (2), ulnar neuropathy (1), deep infection (1), and hematoma (1). Twelve elbows underwent reoperation: 4 for contracture release, 3 for hardware removal, 2 for total elbow arthroplasty, 1 for bone grafting, 1 for hematoma evacuation, and 1 for ulnar nerve neurolysis. Compared to preoperative data, there was a significant improvement in postoperative flexion, extension and pronation (p<0.01). The mean range of motion was 21° of extension, 119° of flexion, 79° of pronation, and 77° of supination. The mean MEPS was 80 points (range, 25 to 100 points) and 19 elbows (76%) rated as excellent or good.
DISCUSSION
Stable fixation and high union rates are possible in distal humerus nonunions with bone loss using a technique that combines supracondylar humeral shortening, parallel plating, and bone grafting. Secondary procedures are commonly needed to restore function in this challenging patient population.
PubMed: 38942224
DOI: 10.1016/j.jse.2024.05.004 -
Journal of Shoulder and Elbow Surgery Jun 2024Coronal shear fractures of the capitellum are rare injuries which can be challenging to treat. The aim of this study was to compare the biomechanical properties of...
OBJECTIVE
Coronal shear fractures of the capitellum are rare injuries which can be challenging to treat. The aim of this study was to compare the biomechanical properties of different internal screw fixation techniques for Dubberley type IA fractures of the capitellum.
METHODS
In this biomechanical study, Dubberley type IA fractures of the capitellum were created in 30 human fresh-frozen humeri. The specimens were then divided into three groups: fixation was either performed with 3 x 3.0 mm headless cannulated compression screws (HCCSs) in anteroposterior (AP) orientation (AP group), 3 x 3.0 mm HCCSs in posteroanterior (PA) orientation (PA group) or with 2 x 3.0 mm HCCSs in PA orientation and 1 x 3.0 mm HCCS in lateral orientation (LAT group). Displacement under cyclic loading and ultimate load-to-failure were evaluated in all specimens.
RESULTS
There was no significant difference in fragment displacement after 2000 cycles between AP and PA groups (0.8 ± 0.5 mm vs. 0.8 ± 0.6 mm; p = 0.987) or PA and LAT groups (0.8 ± 0.6 mm vs. 0.8 ± 0.3 mm; p = 0.966). LAT group showed the highest load-to-failure (548 ± 250 N) without reaching statistically significant difference to AP group (388 ± 173 N; p = 0.101). There was also no significant difference between AP and PA groups (388 ± 173 N vs. 422 ± 114 N; p = 0.649).
CONCLUSIONS
Variations in screw placement had no statistically significant influence on cyclic displacement or load-to-failure in Dubberley Type IA fractures. However, fracture fixation in two planes - both the coronal and the sagittal plane - by adding a screw in a lateral to medial direction may be beneficial to increase primary stability.
PubMed: 38942223
DOI: 10.1016/j.jse.2024.05.007 -
Journal of Shoulder and Elbow Surgery Jun 2024Navigated augmented reality (AR) through a head-mounted display (HMD) has led to accurate glenoid component placement in reverse shoulder arthroplasty (RSA) in an...
Navigated augmented reality through a head-mounted display leads to low deviation between planned, intra- and post-operative parameters during glenoid component placement of reverse shoulder arthroplasty: a proof-of-concept case series.
BACKGROUND
Navigated augmented reality (AR) through a head-mounted display (HMD) has led to accurate glenoid component placement in reverse shoulder arthroplasty (RSA) in an in-vitro setting. The purpose of this study is to evaluate the deviation between planned, intra-, and postoperative inclination, retroversion, entry point and depth of the glenoid component placement during RSA, assisted by navigated AR through a HMD, in a surgical setting.
METHODS
A prospective, multicenter study was conducted. All consecutive patients undergoing RSA in two institutions, between August 2021 and January 2023, were considered potentially eligible for inclusion in the study. Inclusion criteria were: age >18 years, surgery assisted by AR through a HMD, and postoperative computed tomography (CT) scans at six weeks. All participants agreed to participate in the study and an informed consent was provided in all cases. Preoperative CT scans were undertaken for all cases and used for three-dimensional (3D) planning. Intra-operatively, glenoid preparation and component placement were assisted by a navigated AR system through a HMD in all patients. Intraoperative parameters were recorded by the system. A postoperative CT scan was undertaken at 6 weeks, and 3D reconstruction was used for obtaining postoperative parameters. The deviation between planned, intra-, and postoperative inclination, retroversion, entry point, and depth of the glenoid component placement was calculated. Outliers were defined as >5° for inclination and retroversion and >5 mm for entry point.
RESULTS
17 patients (9 females, 12 right shoulders) with a mean age of 72.8±9.1 years old (range, 47.0 to 82.0) met inclusion criteria. The mean deviation between intra- and postoperative measurements was 1.5°±1.0° (range, 0.0° to 3.0°) for inclination, 2.8°±1.5° (range, 1.0° to 4.5°) for retroversion, 1.8±1.0 mm (range, 0.7mm to 3.0mm) for entry point, and 1.9±1.9 mm (range, 0.0mm to 4.5mm) for depth. The mean deviation between planned and postoperative values was 2.5°±3.2° (range, 0.0° to 11.0°) for inclination, 3.4°±4.6° (range, 0.0° to 18.0°) for retroversion, 2.0±2.5 mm (range, 0.0° to 9.7°) for entry point, and 1.3±1.6 mm (range, 1.3mm to 4.5mm) for depth. There were no outliers between intra- and postoperative values and there were three outliers between planned and postoperative values. The mean time (minutes:seconds) for the tracker unit placement and the scapula registration was 03:02 (range, 01:48 to 04:26) and 08:16 (range, 02:09 to 17:58), respectively.
CONCLUSION
The use of a navigated AR system through a HMD in RSA led to low deviations between planned, intra-operative and postoperative parameters for glenoid component placement.
PubMed: 38942222
DOI: 10.1016/j.jse.2024.05.006 -
Arthroscopy : the Journal of... Jun 2024The aim of this study was to present the short-term outcomes of arthroscopic in-situ biceps tenodesis combined with partial rotator cuff repair in patients with massive...
PURPOSE
The aim of this study was to present the short-term outcomes of arthroscopic in-situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCT) and minimal arthritis.
METHODS
A retrospective review was conducted utilizing prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in-situ biceps tenodesis between March 2017 to December 2022. Patients were included if they (1) were diagnosed pre- or intra-operatively with MIRCT, and (2) had complete pre-operative and minimum 1-year post-operative patient-reported outcome measures.
RESULTS
Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range: 46 - 76) with 76.9% (n = 30) being male. The average follow-up was 21 ± 12 months (range: 12 - 58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (p < 0.001 for all comparisons). The pre- to post-operative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, thirty-three patients (84.6%) achieved the MCID for ASES, and thirty patients (76.9%) achieved the MCID for SANE..
CONCLUSIONS
Partial rotator cuff repair with in-situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range of motion measures compared to preoperative conditions.
PubMed: 38942098
DOI: 10.1016/j.arthro.2024.06.018 -
Arthroscopy : the Journal of... Jun 2024The objective of the current study was to analyze if the arthroscopic Bankart repair using a knotless suture anchor has a better functional outcome than the conventional... (Review)
Review
PURPOSE
The objective of the current study was to analyze if the arthroscopic Bankart repair using a knotless suture anchor has a better functional outcome than the conventional knot-tying Bankart repair.
METHODS
Comprehensive literature search was done in Pubmed, Scopus, Embase, and Cochrane databases in May 2023. Studies comparing the clinical outcome of Bankart repair using knotless and knot-tying techniques were included in the study. In vitro, animal, and level 4 and 5 studies were excluded. The risk of bias of randomized controlled trials (RCT) was calculated according to the RoB 2 tool, and for non-randomized studies, MINORS criteria were used. Statistical analysis was done using RevMan software.
RESULTS
A total of nine studies, including two RCT and seven non-randomized comparative studies involving 720 patients, were included in the systematic review. The ROWE score ranged 81.7 to 94.3 in the knot-tying and 86 to 96.3 in the knotless group. VAS scores at final follow-up ranged between 0.1 to 1.7 in the knot-tying and 0.7 to 2.5 in the knotless group. The rate of redislocation, subluxation, and revision surgery in the knot-tying group ranged from 0 to 14.7%, 16.7 to 29.7%, and 1.6 to 17.6%, respectively, while that in the knotless group ranged from 2.4 to 23.8%, 7.4 to 22.2%, and 2.4 to 19%, respectively. The mean external rotation was 54 to 65 degrees in the knot-tying and 61 to 99 in the knotless group. The mean forward-flexion was 164 to 172 in the knot-tying and 165 to 174 in the knotless group. Our subjective synthesis doesn't reveal any difference in the outcome between the two groups.
CONCLUSION
The available literature does not demonstrate a clear difference in functional outcomes, residual pain, and rate of complications like redislocation, subluxation and revision surgery between Bankart repair performed with knotted and knotless anchors.
PubMed: 38942097
DOI: 10.1016/j.arthro.2024.05.036 -
Arthroscopy : the Journal of... Jun 2024Arthroscopic remplissage has been suggested as a means to decrease recurrent instability in arthroscopic Bankart repair surgery involving patients with significant...
Indications for Augmenting Arthroscopic Bankart Procedure with Remplissage in Patients with Non-engaging Hill-Sachs Lesions Must Be Individualized Based on Surgeon and Patient.
Arthroscopic remplissage has been suggested as a means to decrease recurrent instability in arthroscopic Bankart repair surgery involving patients with significant Hill-Sachs lesions. Remplissage fills the H-S lesion to prevent glenohumeral "engagement" and recurrent instability. Remplissage is not generally indicated in patients with smaller, non-engaging Hill-Sachs lesions. However, a recent review suggests that by expanding the indications to non-engaging H-S lesions, recurrence of shoulder instability may be lower in patients having arthroscopic Bankart repair. Further, the review suggests that patients having Bankart plus remplissage did not lose shoulder external rotation range-of-motion. A concern, in addition to follow-up that likely results in underestimation of recurrence, is that anatomically, remplissage should decrease external rotation, and manual measurement of ER could reflect compensatory scapulothoracic motion. This is a particular problem for throwing athletes.
PubMed: 38942096
DOI: 10.1016/j.arthro.2024.06.029