Peter N. Chalmers

Does the Critical Shoulder Angle Correlate With Rotator Cuff Tear Progression

BackgroundThe critical shoulder angle (CSA) has been reported to be associated with rotator cuff disease and has been suggested as an etiology for cuff tears. However, it is unclear whether acromial morphologic characteristics such as CSA are a cause or effect because all studies to date have been retrospective.Questions/purposes(1) How often can the CSA be reliably measured? (2) Is the CSA associated with rotator cuff disease? (3) Is the CSA correlated with baseline tear size or tear enlargement? (4) Does the CSA change with time?MethodsIn this retrospective comparison of longitudinally collected data, patients with asymptomatic rotator cuff tears underwent ultrasonography and standardized AP radiographs at enrollment and yearly thereafter during a median of 4 years. Three hundred ninety-five patients were included, of whom 14 were excluded as they were not yet eligible for 2-year followup and 68 (18%) were lost to followup, leaving 313 study patients who were evaluated with 1433 radiographs. Patients with adhesive capsulitis with normal rotator cuffs and radiographically normal scapulae were included as control subjects (119 subjects). Two observers (PNC, DS) measured the CSA in a blinded fashion. Radiographs that met Suter-Henninger criteria for CSA measurement reliability were included. For the study group, 179 of the 313 (57%) patients with radiographs that met Suter-Henninger criteria were further analyzed; the remainder were excluded from this study. For the control group, 50 of 119 (42%) subjects met criteria and were further analyzed. Tear enlargement was found in 94 patients, and the CSA was compared in patients with tears and control subjects, and in tears with or without enlargement, and was correlated with tear size. In a subgroup of the study group in which 59 of 179 patients had a minimum of 3 years between initial and followup radiographs, two CSA measurements were performed to measure change.ResultsIn total, of the 1552 radiographs evaluated, only 326 (21%) were of sufficient quality to measure the CSA. The CSA was higher among patients with cuff tears than control subjects (34° ± 4° versus 32° ± 4°; mean difference, 2.0°; 95% CI, 0.7°–3.2°; p = 0.003). The CSA did not correlate with baseline tear length (ρ = 0.22, p = 0.090) or width (ρ = 0.16, p = 0.229). The CSA was not different between tears that enlarged and those that were stable (34° ± 3° versus 34° ± 4°; mean difference, 0.2°; 95% CI, −0.9° to −1.4°; p = 0.683). The CSA did not change over time (CSA Time 1: mean 33° ± 4° SD; CSA Time 2: mean 33° ± 4° SD; mean difference, −0.2°; 95% CI, −0.6° to 0.1°; p = 0.253).ConclusionsEven with a longitudinal protocol, most radiographs are of insufficient quality for CSA measurement. Although patients with a history of degenerative cuff disease have higher CSA values than control subjects, the difference is small enough that it could be influenced by measurement error in practice; in any case, a difference of the magnitude we observed is likely to be clinically unimportant. The CSA is not correlated with tear size or tear progression, and does not seem to change with time. These results suggest that the CSA is unlikely to be related to rotator cuff disease.Level of EvidenceLevel II, prognostic study.

Angled BIO-RSA (bony-increased offset-reverse shoulder arthroplasty): a solution for the management of glenoid bone loss and erosion.

BACKGROUNDnGlenoid deficiency and erosion (excessive retroversion/inclination) must be corrected in reverse shoulder arthroplasty (RSA) to avoid prosthetic notching or instability and to maximize function, range of motion, and prosthesis longevity. This study reports the results of RSA with an angled, autologous glenoid graft harvested from the humerus (angled BIO-RSA).nnnMETHODSnA trapezoidal bone graft, harvested from the humeral head and fixed with a long-post baseplate and screws, was used to compensate for residual glenoid bone loss/erosion. For simple to moderate (<25°) glenoid defects, standardized instrumentation combined with some eccentric reaming (<15°) was used to reconstruct the glenoid and obtain neutral implant alignment. For severe (>25°) and complex (multiplanar) glenoid bone defects, patient-specific grafts and guides were used after 3-dimensional planning. Patients were reviewed with minimum 2 years of follow-up. Mean follow-up was 36 months (range, 24-81 months). Preoperative and postoperative measurements of inclination and version were performed in the plane of the scapula on computed tomography images.nnnRESULTSnThe study included 54 patients (41 women, 13 men; mean 73 years old). Fifteen patients had combined vertical and horizontal glenoid bone deficiency. Among E2/E3 glenoids, inclination improved from 37° (range, 14° to 84°) to 10.2° (range -28° to 36°, Pu2009<u2009.001). Among B2/C glenoids, retroversion improved from -21° (range, -49° to 0°) to -10.6° (-32° to 4°, Pu2009=u2009.06). Complete radiographic incorporation of the graft occurred in 94% (51 of 54). Complications included infection in 1 and clinical aseptic baseplate loosening in 2. Mild notching occurred in 25% (13 of 51) of patients. Constant-Murley and Subjective Shoulder Value assessments increased from 31 to 68 and from 30% to 83%, respectively (Pu2009<u2009.001).nnnCONCLUSIONnAngled BIO-RSA predictably corrects glenoid deficiency, including severe (>25°) multiplanar deformity. Graft incorporation is predictable. Advantages of using an autograftharvested in situ include bone stock augmentation, lateralization, low donor-site morbidity, low relative cost, and flexibility needed to simultaneously correct posterior and superior glenoid defects.

Incidence and Return to Play After Biceps Tenodesis in Professional Baseball Players

PURPOSEnTo determine return to play (RTP) rates after biceps tenodesis (BT) in professional baseball players.nnnMETHODSnMajor League Baseball has maintained a prospective database containing all major and minor league baseball players who have undergone shoulder surgery since 2010. All players who had undergone BT were included. Minimum follow-up was 24xa0months, and thus we included data from 2010 to 2013. Using this database we determined the incidence, demographics, prior surgery history, concomitant procedures, RTP rates, and time to RTP.nnnRESULTSnBetween 2010 and 2013, 17 professional baseball players underwent BT. Seventy-one percent of the 17 were pitchers, and 29% of the 17 were in the major league. Forty-seven percent of the 17 had a history of a prior shoulder surgery and 47% of the 17 underwent concomitant labral repair. For all players, RTP after BT was 35%, whereas RTP after BT without a concomitant reconstructive procedure was 44% in 10 ± 6xa0months, and 25% for those who underwent both BT and a concomitant reconstructive procedure (Pxa0= .620). All players who RTP were able to return to at least 20 games at their preoperative level of play. Return to professional play was 80% among position players and 17% among pitchers (Pxa0= .028). For those pitchers who RTP, performance was not statistically changed.nnnCONCLUSIONSnProfessional baseball players who undergo BT have a 35% rate of return to their prior level of play. Whereas pitchers have only a 17% rate of RTP, position players have an 80% rate of RTP. Of those who returned, all returned to their prior level of play. The pitchers who returned had no significant change in performance statistics.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic study, a case series.

Incidence and Changing Trends of Shoulder Stabilization in the United States

PURPOSEnTo determine the incidence and demographic characteristics of shoulder stabilization in the United States, with particular focus on age, sex, and inpatient versus outpatient treatment.nnnMETHODSnThe National Hospital Discharge Survey and the National Survey of Ambulatory Surgery databases were searched using a combination of International Classification of Diseases, Ninth Revision diagnosis and procedure codes, encompassing open and arthroscopic shoulder stabilization procedures. Incidence was determined using National Survey of Ambulatory Surgery, National Hospital Discharge Survey, and US census data, and the results were stratified by age, sex, facility, and concomitant diagnoses. Data were analyzed between 1994 and 2006, the most recent year for which data are available within these sources.nnnRESULTSnThe incidence of shoulder stabilization in the United States was 5.84 per 100,000 person-years (nxa0= 15,514; 95% confidence interval, 11,975-19,053) in 1994 to 1996 and 6.89 per 100,000 person-years (nxa0= 20,588; 95% confidence interval, 16,254-24,922) in 2006 (Pxa0= .0697). The number of inpatient procedures decreased significantly whereas the number of outpatient procedures increased significantly over the same period (P < .0001 for both). The incidence of stabilization increased in patients aged 45 to 64xa0years (P < .0001) and patients aged 65xa0years or older (Pxa0= .0008) but was unchanged in patients aged 44xa0years or younger (Pxa0= .4745). The average age of patients undergoing stabilization increased over the study period, from 30xa0years to 47xa0years for inpatients (Pxa0= .01) and from 27xa0years to 34xa0years for ambulatory patients (Pxa0= .05). The incidence of stabilization increased significantly in male patients (Pxa0= .0075) but remained stable in female patients (Pxa0= .8057) over the same period. Diagnoses related to rotator cuff pathology and shoulder derangement were the most common concurrent diagnosis codes.nnnCONCLUSIONSnThe overall incidence of shoulder stabilization in the United States is 6.89 per 100,000 person-years. The incidence increased by 18% between 1994 and 2006. During the study period, shoulder stabilization shifted to become a largely outpatient procedure, and the average age increased significantly.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Factors Affecting Cost, Outcomes, and Tendon Healing After Arthroscopic Rotator Cuff Repair

BACKGROUNDnThe purpose of this study was to simultaneously examine costs, functional outcomes, and tendon healing after arthroscopic rotator cuff repair.nnnMETHODSnThis was a retrospective, single-surgeon, single-hospital study. Pre- and postoperative Simple Shoulder Test (SST), visual analog scale (VAS) pain, and American Shoulder and Elbow Surgeons (ASES) scores, and postoperative magnetic resonance images (MRIs) were obtained. Direct costs were derived using a unique, validated tool. Costs included overall total direct cost, which included facility use costs, medication costs, supply costs, and other ancillary costs.nnnRESULTSn85 patients had a minimum 1-year follow-up of functional outcomes (mean of 1.24xa0years, range 1-3.2xa0years) and 56 of 85 (66%) had postoperative MRI healing data at an average follow-up of 1.3xa0years (range 1-3.2xa0years). Increased direct cost was associated with ASA class III (P < .001) compared with ASA class I, procedures performed at the main operative room (Pxa0= .017) compared with those at the surgical center, single-row repair (P < .001) compared with double-row repair, medium and large tear sizes (P < .001 and Pxa0= .001) compared with small tear, and increased number of anchors (P ≤ .001 or P < .039 for each additional). Arthroscopic biceps tenodesis was associated with decreased improvement in SST, VAS-pain, and ASES scores (P < .001, .012, and .024), whereas infraspinatus atrophy and large/massive tear size was associated with decreased improvement in ASES scores (Pxa0= .03). Obesity (Pxa0= .004) and smoking (Pxa0= .034) were associated with greater improvement in VAS-pain scores as these were associated with decreased preoperative scores. Seventy percent of tears healed.nnnCONCLUSIONSnWithin our study, factors that increased direct costs were outcome neutral, and factors that improved outcome were cost neutral.nnnLEVEL OF EVIDENCEnLevel IV, retrospective.

Can the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score Be Reliably Administered Over the Phone? A Randomized Study

Background: The Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow outcome score is a functional assessment tool for the upper extremity of the overhead athlete, which is currently validated for administration in person. Purpose/Hypothesis: The purpose of this study was to validate the KJOC score for administration over the phone. The hypothesis was that no difference will exist in KJOC scores for the same patient between administration in person versus over the phone. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Fifty patients were randomized to fill out the KJOC questionnaire either over the phone first (25 patients) or in person first (25 patients) based on an a priori power analysis. One week after the patients completed the initial KJOC on the phone or in person, they then filled out the score via the opposite method. Results were compared per question and for overall score. Results: There was a mean ± SD of 8 ± 5 days between when patients completed the first and second questionnaires. There were no significant differences in the overall KJOC score between the phone and paper groups (P = .139). The intraclass correlation coefficient comparing paper and phone scores was 0.802 (95% CI, 0.767-0.883; P < .001), with a Cronbach alpha of 0.89. On comparison of individual questions, there were significant differences for questions 1, 3, and 8 (P = .013, .023, and .042, respectively). Conclusion: The KJOC questionnaire can be administered over the phone with no significant difference in overall score as compared with that from in-person administration.

Relationship Between Pitching a Complete Game and Spending Time on the Disabled List for Major League Baseball Pitchers

Background: Injury rates among Major League Baseball pitchers have been increasing over the past several years. It is currently unknown whether pitching a complete game (CG) is a risk factor for spending time on the disabled list (DL). Purpose/Hypothesis: The purpose of this study was to determine the relationship between pitching a CG and time on the DL. We hypothesized that pitchers who threw a CG (1) would be at increased risk for spending time on the DL, which would be earlier in the season and for a longer period, than those who did not and (2) would be at further increased risk for spending time on the DL during subsequent seasons than matched controls. Study Design: Descriptive epidemiology study. Methods: Pitchers who threw a CG between 2010 and 2016 at the major league level and were placed on the DL during the same season were included. Timing and length of period on the DL were determined, as well as placement on the DL during subsequent seasons. Matched controls who did not throw a CG were assessed for time spent on the DL during that season and subsequent seasons. Results: Overall, 246 individual pitchers (501 pitcher-seasons) threw at least 1 CG between 2010 and 2016. Of the pitcher-seasons, 370 (73.9%) included a period on the DL, as compared with only 20% of controls. There were no differences in length of time on the DL (P = .928) or days from season start to time on the DL (P = .861) between pitchers who threw a CG and controls. Pitchers who threw a CG were significantly more likely than controls to spend subsequent seasons on the DL (1.9 ± 1.1 vs 0.5 ± 0.9, P < .001). Conclusion: Overall, 74% of pitchers who threw a CG spent time on the DL, as compared with 20% of controls. Pitchers who threw a CG during the study period spent more time in subsequent seasons on the DL than did matched controls who did not throw a CG.

Total shoulder arthroplasty in patients with a B2 glenoid addressed with corrective reaming

BACKGROUNDnThis study describes the short-term functional and radiographic outcomes after total shoulder arthroplasty (TSA) in shoulders with a B2 glenoid deformity addressed with corrective reaming.nnnMETHODSnWe conducted a retrospective series of consecutive patients who underwent TSA with a Walch B2 glenoid quantified by computed tomography scan. All glenoid deformities were addressed using partially corrective glenoid reaming. Radiographic and functional outcome measures, including scores on the visual analog scale for pain, American Shoulder and Elbow Standardized Shoulder Assessment, and Simple Shoulder Test were collected.nnnRESULTSnFunctional outcome scores were available for 59 of 92 eligible subjects (64%) at a mean of 50 months. The mean preoperative retroversion measured 18° (range, -1° to 36°), superior inclination was 8° (range, -11° to 27°), and posterior subluxation was 67% (range, 39%-91%). Mean visual analog scale improved from 7.4 to 1.4, the American Shoulder and Elbow Shoulder Standardized Assessment improved from 35.4 to 84.3, and the SST improved from 4.5 to 9.1. Radiographs were evaluated at a mean of 31 months: 38 had no glenoid radiolucent lines, 13 glenoids had grade 1, 2 had grade 2, and 5 had grade 3 lucencies. There was no difference in the rate of progression of glenoid radiolucencies between shoulders with a preoperative glenoid version of ≤20° (27.8%) compared with glenoids with >20° of retroversion (22.7%, Pu2009=u2009.670). No shoulders were revised due to glenoid loosening or instability.nnnCONCLUSIONnTSA with partial corrective glenoid reaming in selected shoulders with a B2 glenoid deformity resulted in excellent functional and radiographic outcomes at short-term follow-up, with a low risk of revision surgery.

Superior glenoid inclination and rotator cuff tears.

BACKGROUNDnThe objectives of this study were to determine whether glenoid inclination (1) could be measured accurately on magnetic resonance imaging (MRI) using computed tomography (CT) as a gold standard, (2) could be measured reliably on MRI, and (3) whether it differed between patients with rotator cuff tears and age-matched controls without evidence of rotator cuff tears or glenohumeral osteoarthritis.nnnMETHODSnIn this comparative retrospective radiographic study, we measured glenoid inclination on T1 coronal MRI corrected into the plane of the scapula. We determined accuracy by comparison with CT and inter-rater reliability. We compared glenoid inclination between patients with full-thickness rotator cuff tears and patients aged >50 years without evidence of a rotator cuff tear or glenohumeral arthritis. An a priori power analysis determined adequate power to detect a 2° difference in glenoid inclination.nnnRESULTSn(1) In a validation cohort of 37 patients with MRI and CT, the intraclass correlation coefficient was 0.877, with a mean difference of 0° (95% confidence interval, -1° to 1°). (2) For MRI inclination, the inter-rater intraclass correlation coefficient was 0.911. (3) Superior glenoid inclination was 2° higher (range, 1°-4°, Pu2009<u2009.001) in the rotator cuff tear group of 192 patients than in the control cohort of 107 patients.nnnCONCLUSIONSnGlenoid inclination can be accurately and reliably measured on MRI. Although superior glenoid inclination is statistically greater in those with rotator cuff tears than in patients of similar age without rotator cuff tears or glenohumeral arthritis, the difference is likely below clinical significance.

Do magnetic resonance imaging and computed tomography provide equivalent measures of rotator cuff muscle size in glenohumeral osteoarthritis

BACKGROUNDnRotator cuff muscle volume is associated with outcomes after cuff repair and total shoulder arthroplasty. Muscle area on select magnetic resonance imaging (MRI) slices has been shown to be a surrogate for muscle volume. The purpose of this study was to determine whether computed tomography (CT) provides an equivalent measurement of cuff muscle area to a previously validated MRI measurement.nnnMETHODSnWe included 30 patients before they were undergoing total shoulder arthroplasty with both preoperative CT and MRI scans performed within 30 days of one another at 1 institution using a consistent protocol. We reoriented CT sagittal and MRI sagittal T1 series orthogonal to the scapular plane. On both CT and MRI scans, we measured the area of the supraspinatus, infraspinatus-teres minor, and subscapularis on 2 standardized slices as previously described. We calculated intraclass correlation coefficients and mean differences.nnnRESULTSnFor the 30 subjects included, when MRI and CT were compared, the mean intraclass correlation coefficients were 0.989 (95% confidence interval [CI], 0.976-0.995) for the supraspinatus, 0.978 (95% CI, 0.954-0.989) for the infraspinatus-teres minor, and 0.977 (95% CI, 0.952-0.989) for the subscapularis. The mean differences were 0.2 cm2 (95% CI, 0.0-0.4 cm2) for the supraspinatus (Pu2009=u2009.052), 0.8 cm2 (95% CI, 0.1-1.4 cm2) for the infraspinatus-teres minor (Pu2009=u2009.029), and -0.3 cm2 (95% CI, -1.2 to 0.5 cm2) for the subscapularis (Pu2009=u2009.407).nnnCONCLUSIONnCT provides nearly equivalent measures of cuff muscle area to an MRI technique with previously validated reliability and accuracy. While CT underestimates the infraspinatus area as compared with MRI, the difference is less than 1u2009cm2 and thus likely clinically insignificant.