Gregory P. Nicholson

The Role of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis

PURPOSE Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP. METHODS We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. RESULTS Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. CONCLUSIONS PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings. LEVEL OF EVIDENCE Level III, systematic review of Level I, II, and III studies.

Arthroscopic resection of the distal clavicle with a superior approach

Forty-one patients (41 shoulders) with acromioclavicular joint disease refractory to conservative treatment underwent arthroscopic distal clavicle resection. Thirty-one men and 10 women with an average age of 32 years were studied. The dominant extremity was involved in 68% of the patients. At an average follow-up period of 31 months (range 24 to 49 months), 18 excellent, 16 good, and seven poor results were found. Twenty-seven (93%) of 29 shoulders with acromioclavicular arthritis or osteolysis of the distal clavicle went on to have satisfactory results compared with only seven (58%) of 12 shoulders with previous grade II acromioclavicular separations or acromioclavicular hypermobility. Total amount of bone removal did not correlate with success, if the resection was even. Five reoperations were done; one uneven resection was revised with arthroscopy, and four shoulders underwent acromioclavicular stabilization procedures. The high failure rate in patients with even subtle acromioclavicular instability (42%) suggests that in these cases formal stabilization with ligament reconstruction should be considered in addition to resection of the distal clavicle.

Outcomes of Arthroscopic Rotator Cuff Repair in Patients Aged 70 Years or Older

PURPOSE To evaluate outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. METHODS We identified 44 consecutive patients aged 70 years or older undergoing primary all-arthroscopic repair of symptomatic full-thickness tears of the rotator cuff. A minimum 2-year follow-up was performed by an independent examiner including range of motion and dynamometer strength testing, and shoulder functional outcome scores including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and pain score on a visual analog scale were determined. Paired t tests were performed to compare preoperative and postoperative measures. Postoperative Constant-Murley scores were normalized with scores from age- and sex-matched healthy individuals. RESULTS Of the patients, 39 (88.6%) were available for follow-up evaluation, with a mean age of 75.3 ± 4.2 years (range, 70.1 to 89.8 years) and a mean follow-up of 36.1 ± 9.9 months (range, 24.3 to 59.4 months). The American Shoulder and Elbow Surgeons score improved from 45.8 ± 16.6 (mean ± SD) to 87.5 ± 14.4 at final follow-up (P < .0001). The Simple Shoulder Test score improved from 3.9 ± 2.3 to 9.8 ± 2.5 (P < .0001). The pain score on the visual analog scale improved from 4.6 ± 2.2 to 0.5 ± 0.9 (P < .0001), and forward elevation increased from 114.8° ± 42.0° to 146.2° ± 33.2° (P = .0012). Mean age- and sex-matched normalized Constant-Murley scores ranged from 88.3% to 97.2% of normal in men and 81.7% to 88.8% of normal in women. CONCLUSIONS Arthroscopic rotator cuff repair provides significant improvement in pain and function in carefully selected patients aged 70 years or older with symptomatic full-thickness rotator cuff tears and has a low complication rate. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Treatment and results of sternoclavicular joint injuries

Sternoclavicular joint injuries are uncommon. The anatomy is not familiar to most orthopaedic surgeons, and there is a high risk of both intraoperative catastrophic and postsurgical complications when performing surgery in this region. Anterior SC joint instability should primarily be treated conservatively. The patients should be informed that there is a high risk of persistent instability with nonoperative or operative care, but that the persistent instability will be well tolerated and have little functional impact in the vast majority. Therefore, operative intervention for anterior SC joint instability is mainly cosmetic in nature. Patients with posterior SC joint dislocations require an expeditious diagnosis and treatment, due to the proximity of the displaced medial clavicle to the great vessels. An early closed reduction will usually be stable. Operative stabilization must, however, be considered if the closed reduction is unsuccessful or there is persistent SC instability. SC joint stabilization should be performed with a soft tissue reconstruction, repairing both the costoclavicular ligaments and the SC capsular envelope.

Retrospective analysis of arthroscopic management of glenohumeral degenerative disease.

PURPOSE The purpose of this study was to examine the results of arthroscopic debridement for isolated degenerative joint disease of the shoulder. METHODS We retrospectively identified 81 patients who had arthroscopic debridement to treat glenohumeral arthritis. Of these patients, 71 (88%) were available for follow-up. The preoperative Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, Short Form 12 score, visual analog scale score for pain, and range of motion were recorded. These were compared against postoperative scores by use of the statistical paired t test. In addition, patients completed postoperative University of California, Los Angeles; Constant; and Single Assessment Numeric Evaluation scores. Forty-six preoperative radiographs were blindly evaluated and classified. Finally, the need for subsequent shoulder arthroplasty was recorded. RESULTS The mean follow-up for the 55 patients who did not progress to arthroplasty was 27 months. The mean preoperative and postoperative American Shoulder and Elbow Surgeons, Simple Shoulder Test, and pain visual analog scale scores all significantly improved (P < .05). Furthermore, range of motion significantly improved (P < .05) in flexion, abduction, and external rotation. Additional postoperative scores were as follows: University of California, Los Angeles, 28.3; Single Assessment Numeric Evaluation, 71.1; Constant score for affected shoulder, 72.0; and Constant score for unaffected shoulder, 78.5. Of the patients, 16 (22%) underwent arthroplasty at a mean of 10.1 months after debridement. Radiographic review showed that 13 shoulders with a mean joint space of 1.5 mm and grade 2.4 arthrosis went on to have shoulder arthroplasty. In contrast, 33 shoulders with a mean joint space of 2.6 mm and grade 1.9 arthrosis did not go on to have shoulder arthroplasty. CONCLUSIONS Patients with residual joint space and an absence of large osteophytes can avoid arthroplasty and have increased function with decreased pain after arthroscopic debridement for degenerative joint disease. Significant risk factors for failure include the presence of grade 4 bipolar disease, joint space of less than 2 mm, and large osteophytes. LEVEL OF EVIDENCE Level IV, case series.

Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty

BACKGROUND Significant controversy surrounds optimal treatment of displaced 4-part proximal humeral fractures. Reverse total shoulder arthroplasty (RTSA) has recently been proposed as an alternative to hemiarthroplasty (HA) and open reduction-internal fixation (ORIF). Several authors have questioned the additional implant cost for RTSA. The purpose of this study was to compare outcomes and cost of RTSA, HA, and ORIF. MATERIALS AND METHODS We prospectively evaluated patients who underwent RTSA for displaced 3- and 4-part proximal humeral fractures and then retrospectively developed age- and sex-matched control groups with 3- and 4-part proximal humeral fractures who underwent HA and ORIF. Range of motion including active forward elevation and external rotation and time to achieve active forward elevation >90° were recorded. American Shoulder and Elbow Surgeons (ASES), Short-Form 12-item (SF-12), and Simple Shoulder Test (SST) scores were recorded. In addition, treatment cost was assessed by Medicare data and implant list prices. RESULTS This study enrolled 27 patients; 9 underwent RTSA, 9 HA, and 9 ORIF. Minimum follow-up was 1 year. No significant differences were seen in SST, ASES, or SF-12 scores. Significantly more patients achieved >90° of active forward elevation after RTSA (P = .012). RTSA provided significant cost savings to Medicare compared with HA and ORIF (P = .002.) CONCLUSION In this case-control study, RTSA appears to provide superior range of motion earlier and more predictably than HA and ORIF, with significant cost savings to Medicare.

The Kinetic Chain in Overhand Pitching: Its Potential Role for Performance Enhancement and Injury Prevention

The overhead throwing motion is a coordinated effort of muscle units from the entire body, culminating with explosive motion of the upper extremity. The throwing motion occurs at a rapid pace, making analysis difficult in real time. Electromyographic studies and high-speed video recordings have provided invaluable details regarding the involved musculature, the sequence of muscle involvement, and associated kinematic variables. The goal of the present article is to provide an overview of the kinetic chain—that is, a detailed description of the muscular coordination during each phase of pitching—and to describe specific types of pitches. An enhanced understanding of the components of the kinetic chain and the phases of the throwing motion can provide important information for rehabilitation, performance enhancement, and injury prevention.

Reverse total shoulder arthroplasty in patients of varying body mass index

BACKGROUND Body mass index (BMI) is an independent predictor of complications after hip and knee arthroplasty. Whether similar trends apply to patients undergoing reverse total shoulder arthroplasty (RTSA) is unknown. METHODS A retrospective review of primary RTSAs with a minimum 90-day follow-up were included. Complications were classified as major or minor and medical or surgical. Patients were classified into 3 groups: normal BMI (BMI <25 kg/m(2)), overweight or mildly obese (BMI 25-35 kg/m(2)), and moderately or severely obese (BMI >35 kg/m(2)). RESULTS Of the 119 patients met our inclusion criteria, 30 (25%) had a BMI of less than 25 kg/m(2); 65 (55%) had a BMI of 25 to 35 kg/m(2), and 24 (20%) had BMI exceeding 35 kg/m(2). Complications occurred in 30 patients (25%), comprising major in 11 (9%), minor in 19 (16%), surgical in 21 (18%), and medical in 14 (12%). The most common surgical complications were acute blood loss anemia requiring transfusion (8.4%) and dislocation (4.2%). The most common medical complications were atelectasis (2.5%) and acute renal insufficiency (2.5%). Patients with a BMI exceeding 35 kg/m(2) had a significantly higher overall complication rate (P < .05) and intraoperative blood loss (P = .05) than the other groups. Patients with BMI of less than 25 kg/m(2) had a greater overall complication rate than those with a BMI of 25 to 35 kg/m(2) (P < .05). Multivariate regression analysis demonstrated BMI was the only significant determinant of overall complication rates and medical complication rates (P < .05). CONCLUSION Patients with a BMI exceeding 35 kg/m(2) (severely obese) or a BMI of less than 25 kg/m(2) have higher rates of complication after RTSA.

Outcomes After Arthroscopic Revision Rotator Cuff Repair

Background Although a number of reports have documented outcomes after open revision rotator cuff repair, there are few studies reporting results after arthroscopic revision. Hypothesis Arthroscopic repair of failed rotator cuff results in significant improvement in shoulder functional outcome and pain relief. Study Design Case series; Level of evidence, 4. Methods Multiple variables including demographic data, the number of prior ipsilateral shoulder surgeries, and tear size were recorded from chart review. An independent examiner then measured shoulder strength, range of motion, and shoulder functional outcome scores including American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog pain scale. Paired t tests were performed to compare preoperative and postoperative measures. Additionally, contingency table analysis was performed to identify prognostic factors for failure of repair requiring further surgery and American Shoulder and Elbow Surgeons score less than 50. Results Fifty-four patients (88.5%) were available for follow-up evaluation with a mean age of 54.9 ± 10.1 years (range, 22.7-82.5 years) and a mean follow-up of 31.1 ± 11.9 months. American Shoulder and Elbow Surgeons scores improved from 43.8 ± 5.7 (mean ± 95% confidence interval) before revision to 68.1 ± 7.2 at final follow-up (P = .0039). The Simple Shoulder Test improved significantly from 3.56 ± 0.8 before surgery to 7.5 ± 1.1 at most recent follow-up (P < .0001). Visual analog pain scale scores improved from 5.17 ± 0.8 to 2.75 ± 0.8 (P = .03), and forward elevation increased from 121.0° ± 12.3° to 136° ± 11.8° postoperatively (P = .025). Greater than 1 prior shoulder surgery was associated with cases that required additional surgery (P = .031). Female gender (P = .007) and preoperative abduction less than 90° (P = .009) were associated with American Shoulder and Elbow Surgeons scores less than 50. Conclusion Arthroscopic revision rotator cuff repair may be a reasonable treatment option even after prior open repairs and provides both improved pain relief and shoulder function. Nonetheless, results are not completely optimal. Female patients and those who have undergone more than 1 ipsilateral shoulder surgery are at increased risk for poorer results.

Early dislocation after reverse total shoulder arthroplasty

BACKGROUND Although instability can occur after reverse total shoulder arthroplasty (RTSA), the risk factors, the treatment, and ultimate fate of the implant in these patients remains poorly understood. METHODS Demographics, acute treatment, and the need for revision were evaluated in all patients with RTSAs who sustained a subsequent dislocation within the first 3 months. Standardized outcome scores were collected preoperatively and at the final follow-up. RESULTS Atraumatic instability occurred in 11 patients (incidence, 2.9%) treated with RTSA early (before 3 months postsurgery). The mean time to dislocation was 3.4 weeks. These patients tended to be previously operated-on (64%), male (82%), overweight (mean body mass index (BMI) of 32.2 kg/m(2), with 82% having a BMI ≥30 kg/m(2)), and without a satisfactory subscapularis repair at initial RTSA (64%). Initial treatment included closed reduction in 9 patients, open reduction in 1, and open reduction with a thicker polyethylene insert in 1. Four experienced recurrent instability requiring a thicker polyethylene insert. Two additional patients were converted to hemiarthroplasty due to persistent instability. Visual analog pain scores (P = .014) and American Shoulder and Elbow Surgeons scores (P = .018) were significantly improved. Simple Shoulder Test scores trended towards improvement (P = .073). CONCLUSIONS Early dislocations of the RTSA prosthesis were uncommon. The most common associated factors were a BMI >30 kg/m(2), male gender, subscapularis deficiency, and previous surgery; in these patients, we now use an abduction orthosis. Closed reduction alone was successful in 4 of the 9 closed reductions (44%). Five of 11 RTSAs (45%) required polyethylene exchange. The RTSA was retained in 82%, 36% with the original implant.