Alicia K. Harrison

National Trends in Rotator Cuff Repair

BACKGROUNDnRecent publications suggest that arthroscopic and open rotator cuff repairs have had comparable clinical results, although each technique has distinct advantages and disadvantages. National hospital and ambulatory surgery databases were reviewed to identify practice patterns for rotator cuff repair.nnnMETHODSnThe rates of medical visits for rotator cuff pathology, and the rates of open and arthroscopic rotator cuff repair, were examined for the years 1996 and 2006 in the United States. The national incidence of rotator cuff repairs and related data were obtained from inpatient (National Hospital Discharge Survey, NHDS) and ambulatory surgery (National Survey of Ambulatory Surgery, NSAS) databases. These databases were queried with use of International Classification of Diseases, Ninth Revision (ICD-9) procedure codes for arthroscopic (ICD-9 codes 83.63 and 80.21) and open (code 83.63 without code 80.21) rotator cuff repair. We also examined where the surgery was performed (inpatient versus ambulatory surgery center) and characteristics of the patients, including age, sex, and comorbidities.nnnRESULTSnThe unadjusted volume of all rotator cuff repairs increased 141% in the decade from 1996 to 2006. The unadjusted number of arthroscopic procedures increased by 600% while open repairs increased by only 34% during this time interval. There was a significant shift from inpatient to outpatient surgery (p < 0.001).nnnCONCLUSIONSnThe increase in national rates of rotator cuff repair over the last decade has been dramatic, particularly for arthroscopic assisted repair.

Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?

HYPOTHESISnConservative rehabilitation after arthroscopic rotator cuff repair does not result in long-term stiffness and improves rates of tendon healing.nnnMATERIALS AND METHODSnWe retrospectively evaluated 43 patients with full-thickness rotator cuff tears who underwent a standardized, conservative protocol of full-time sling immobilization without formal therapy for 6 weeks after arthroscopic repair. At 6 to 8 weeks of follow-up, we categorized patients as stiff if they demonstrated forward elevation of less than 100° and external rotation of less than 30° passively; all others were designated nonstiff. Active range of motion in forward elevation, external rotation, and internal rotation was assessed at 3 months, 6 months, and 1 year. American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores were assessed at 1 year. Follow-up magnetic resonance imaging (MRI) was obtained in all patients to assess tendon healing.nnnRESULTSnTen patients (23%) were considered stiff after rotator cuff surgery. At 1 year, there was no difference in mean forward elevation (166° vs 161°, P = .2), external rotation (62° vs. 58.4°, P = .5), or internal rotation (T7.4 vs T8.2, P = .07) between the stiff and nonstiff groups, respectively. There were no differences in final ASES (83 vs 79, P = .57) and Constant-Murley scores (77 vs. 74, P = .5). Repeat MRI suggested a trend toward a lower retear rate among the stiff patients (70% intact in stiff group vs 36% in nonstiff group, P = .079). Two clinically significant cuff retears occurred in the nonstiff cohort.nnnDISCUSSIONnConcerns for recalcitrant stiffness have led some to favor early postoperative therapy. We found that early restriction of motion did not lead to long-term stiffness after arthroscopic rotator cuff repair, even in patients who were clinically stiff in the early postoperative period.nnnCONCLUSIONSnSling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing.

Where to tenodese the biceps: proximal or distal?

BackgroundThe best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove.Questions/purposesWe asked the following questions: (1) Does a higher tenodesis in the biceps groove result in postoperative pain? And (2) can the tenodesis location be successfully moved more distally (“suprapectoral tenodesis”) by an arthroscopic technique?MethodsWe retrospectively reviewed 17 patients undergoing arthroscopic biceps tenodesis and evaluated their tenodesis location, either within the upper half of the groove (five) or in the lower half of the groove or shaft (12). Patient outcomes were assessed with visual analog scale scores for pain, American Shoulder and Elbow Surgeons scores, and Constant-Murley scores. Minimum followup was 12xa0months (mean, 28xa0months; range, 12–69xa0months).ResultsTwo patients had persistent pain at 12xa0months; both had a tenodesis in the upper half of the groove. The overall American Shoulder and Elbow Surgeons and Constant-Murley scores were improved at latest followup.ConclusionsArthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. Our preliminary observations suggest a more distal tenodesis location may decrease the incidence of persistent postoperative pain at the bicipital groove, although additional research is needed to definitively state whether the proximal location is in fact more painful.Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Subacromial impingement syndrome.

&NA; Subacromial impingement syndrome (SIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full‐thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. Both extrinsic compression and intrinsic degeneration may play a role. Management includes physical therapy, injections, and, for some patients, surgery. There remains a need for high‐quality studies of the pathology, etiology, and management of SIS.

A History of Reverse Total Shoulder Arthroplasty

BackgroundManagement of the cuff-deficient arthritic shoulder has long been challenging. Early unconstrained shoulder arthroplasty systems were associated with high complication and implant failure rates. The evolution toward the modern reverse shoulder arthroplasty includes many variables of constrained shoulder arthroplasty designs.Questions/purposesThis review explores the development of reverse shoulder arthroplasty, specifically describing (1) the evolution of reverse shoulder arthroplasty designs, (2) the biomechanical variations in the evolution of this arthroplasty, and (3) the current issues relevant to reverse shoulder arthroplasty today.MethodsUsing a PubMed search, the literature was explored for articles addressing reverse shoulder arthroplasty, focusing on those papers with historical context.ResultsResults of the early designs were apparently poor, although they were not subjected to rigorous clinical research and usually reported only in secondary literature. We identified a trend of glenoid component failure in the early reverse designs. This trend was recognized and reported by authors as the reverse shoulder evolved. Authors reported greater pain relief and better function in reverse shoulder arthroplasty with the fundamental change of Grammont’s design (moving the center of rotation medially and distally). However, current reports suggest lingering concerns and challenges with today’s designs.ConclusionsThe history of reverse shoulder arthroplasty involves the designs of many forward-thinking surgeons. Many of these highly constrained systems failed, although more recent designs have demonstrated improved longevity and implant performance. Reverse shoulder arthroplasty requires ongoing study, with challenges and controversies remaining around present-day designs.

Intermediate Outcomes Following Percutaneous Fixation of Proximal Humeral Fractures

BACKGROUNDnMini-open reduction and percutaneous fixation of proximal humeral fractures historically results in good outcomes and a low prevalence of osteonecrosis reported with short-term follow-up. The purpose of this study was to determine the midterm results of our multicenter case series of proximal humeral fractures treated with percutaneous fixation.nnnMETHODSnBetween 1999 and 2006, thirty-nine patients were treated with percutaneous reduction and fixation for proximal humeral fractures at three tertiary shoulder referral centers. Twenty-seven of these patients were available for intermediate follow-up at a minimum of three years (mean, eighty-four months; range, thirty-seven to 128 months) after surgery; the follow-up examination included use of subjective outcome measures and radiographic analysis to identify osteonecrosis and posttraumatic osteoarthritis on radiographs.nnnRESULTSnOsteonecrosis was detected in seven (26%) of the total group of twenty-seven patients at a mean of fifty months (range, eleven to 101 months) after the date of percutaneous fixation. Osteonecrosis was observed in five (50%) of the ten patients who had four-part fractures, two (17%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Posttraumatic osteoarthritis, including osteonecrosis, was present on radiographs in ten (37%) of the total group of twenty-seven patients. Posttraumatic osteoarthritis was observed in six (60%) of the ten patients who had four-part fractures, four (33%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures.nnnCONCLUSIONSnIntermediate follow-up of patients with percutaneously treated proximal humeral fractures demonstrates an increased prevalence of osteonecrosis and posttraumatic osteoarthritis over time, with some patients with these complications presenting as late as eight years postoperatively. Development of osteonecrosis did not have a universally negative impact on subjective outcome scores.

Arthroscopic decompression with acromioplasty and structured exercise was no more effective and was more expensive than exercise alone.

Question: In patients with shoulder impingement syndrome, what is the effectiveness and cost-effectiveness of arthroscopic decompression with acromioplasty and structured exercise compared with structured exercise alone? Design: Randomized (allocation concealed), blinded (outcome assessor) controlled trial with 2-year follow-up. Setting: 2 hospitals in Finland. Patients: 140 patients (18 to 60 years ofage; mean age, 47 y; 63% women) who had suspected shoulder impingement syndrome. Inclusion criteria were a positive Neer test; shoulder pain resistant to rest, anti-inflammatory drugs, subacromial glucocorticosteroid injections, and physiotherapy; and symptoms persisting for 3 months. Exclusion criteria were glenohumeral or acromioclavicular osteoarthritis, signs of glenohumeral instability, previous surgery to the affected shoulder, full-thickness tear of the rotator cuff, cervical radicular syndrome, adhesive capsulitis, or neuropathy of the shoulder area. End-point data were available for 134 patients (96%). Intervention: Patients were allocated to combined surgery plus structured exercise (n = 70) or exercise alone (n = 70). The structured exercise program consisted of an individually tailored home-exercise regimen that aimed to restore painless and normal mobility of the shoulder complex and increase the dynamic stability of the glenohumeral joint and scapula. Training involved the use of stretch bands and light weights. Sessions were held 4 times per week with use of 9 different exercises with 30 to 40 repetitions 3 times. As ability and strength improved, the resistance was increased and the repetitions were decreased. During arthroscopic decompression, the arthroscope was introduced through a standard posterior portal and debridement and decompression were done by shaver or vaporizer. Acromioplasty was performed with a burr drill, starting anteriorly and progressing posterolaterally. 7 to 10 days after surgery, sutures and dressings were removed and patients received the same individually tailored exercise program as provided to the exercise-alone group. Main outcome measures: The primary outcome was self-reported pain on a visual analog scale (VAS) of 0 to 10 (0 = no pain, 10 = maximum imaginable pain; 1.5 was the minimal clinically important difference). Secondary outcomes were disability, pain at night, working ability, shoulder questionnaire score, number of painful days in the previous 3 months, and the proportion of pain-free patients (VAS ≤3). Costs were in 2004 prices (€) and included direct healthcare (operation, hospitalization) and non-healthcare (travel, massage, manipulation) resources. Main results: Analysis was by intention to treat. The study had sufficient power to detect at least a 1.5-unit difference in self-reported pain between combined treatment and exercise. A decrease in self-reported pain exceeding the minimal clinically important difference occurred in both the combined treatment and exercise-alone groups. Between-group differences were not significant (Table). The groups were not different for any of the secondary outcomes. The mean total cost was €2961 in the combined treatment group and €1864 in the exercise group (mean incremental cost €1097). The incremental cost-effectiveness ratio was €5431 per minimal clinically important difference unit With a willingness to pay of €8000 for 1 additional minimal clinically important difference unit, the probability that combined treatment would be acceptable was 56%.

Outcomes of Open and Arthroscopic Subscapularis Repairs (SS-18)

Introduction Injury to the subscapularis tendon can be a cause of significant shoulder dysfunction. Diagnosis can be complex and therefore may be delayed. There is minimal literature on outcomes seen after subscapularis repair but some studies suggest shoulder function after rotator cuff repair is poorer in the setting of subscapularis repair. We present one-year minimum follow-up of a series of both arthroscopic and open subscapularis repairs. Methods We retrospectively reviewed 39 patients with one year follow-up after open or arthroscopic repair of a full-thickness subscapularis tear. Tear size (upper third, upper half, or entire subscapularis tendon) and pattern were recorded and any concomitant procedures documented. Preoperative and postoperative physical exams were completed including range of motion and the presence or absence of an abnormal stomach press. ASES and Constant scores were completed at 1 year by 24 of the total 39 patients. Results An open repair was performed in 17 patients and an arthroscopic repair in 22 patients. Average follow-up was 29 months (range 12-75 months). At most recent postoperative follow-up, the average active range of motion was forward elevation to 140 degrees, external rotation to 53 degrees, and internal rotation to T10. There was no significant difference in postoperative motion between open and arthroscopic repairs. Of those patients with an abnormal stomach press preoperatively, 48% continued to demonstrate an abnormal stomach press at latest follow-up. In those completing subjective outcome scores, the average ASES score was 76 and average Constant score was 73. There was no difference in range of motion, ASES, or Constant scores based on size of tear. Conclusion Outcomes of open and arthroscopic subscapularis repairs were equivalent. In addition, tear size was not predictive of outcome suggesting even complete subscapularis tears may do well after either open or arthroscopic repair. Though a complete repair was performed in all patients, nearly half of patients with an abnormal stomach press preoperatively were unable to perform a normal test postoperatively.