Richard J. Hawkins

Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis

BACKGROUNDnDespite improved results with reverse shoulder arthroplasty (RSA), questions still remain regarding certain technical aspects of the operation. One particular area of question is the effect of subscapularis repair on complication rates, dislocation, pain, and overall range of motion. Some authors suggest that when a deltopectoral approach is used, not repairing the subscapularis leads to a higher complication rate, especially for dislocation.nnnMATERIALS AND METHODSnFrom a reverse total shoulder arthroplasty database of 3 surgeons at 1 institution, we identified 55 patients who underwent RSA using the deltopectoral approach without subscapularis repair and 65 patients with subscapularis repair.nnnRESULTSnComplications were documented in 11 of 55 shoulders (20%) without subscapularis repair and in 13 of 65 shoulders (20%) with subscapularis repair. Dislocation occurred in 3 shoulders in the nonrepair group and in 2 shoulders in the repair group. These data indicate that nonrepair of the subscapularis did not have a significant effect on the risk of any complication, dislocation, infection, disassociation, or function.nnnCONCLUSIONnRepairing the subscapularis has no appreciable effect on complication rate, dislocation events, or range of motion gains and pain relief.

Management of deep infection after reverse total shoulder arthroplasty: a case series

BACKGROUNDnReverse total shoulder arthroplasty (RSA) is being increasingly used in the treatment of disabling shoulder conditions. This study reports the management of deep infections after RSA.nnnMATERIALS AND METHODSnEight of 138 patients were treated for deep infection after the index procedure. A retrospective review was performed to identify risk factors, methods of management, and determine ultimate outcome. A minimum of 12-month follow-up was available in 7 of 8 patients.nnnRESULTSnSix infections occurred in patients who had had previous shoulder surgery. The causative bacterial organism was identified in 6 patients. Deep infection occurred in 3 patients with diabetes mellitus. Antibiotic cement was used in all cases. Six patients were managed with irrigation and debridement and retention of components. Two patients with of Staphylococcus aureus infection ultimately required resection arthroplasty. Patients managed with irrigation and debridement, intravenous antibiotics, and retention of components demonstrated good pain relief and function, without evidence of radiographic loosening. Resection resulted in pain relief but poor functional outcomes.nnnCONCLUSIONnLimited literature is available regarding the management of deep infection in patients with RSA. Component removal after a RSA creates increased bone loss due to a cemented humeral component and glenoid baseplate with several large screws. Five of 7 patients with deep infection had undergone previous shoulder surgery. We recommend that patients should be managed with an initial irrigation and debridement, appropriate intravenous antibiotics, and component retention.

Accuracy of glenohumeral joint injections: comparing approach and experience of provider

BACKGROUNDnThe purpose of this study was to prospectively evaluate the accuracy of three different approaches used for glenohumeral injections. In addition, the accuracy of the injection was compared to the experience and confidence of the provider.nnnMETHODSnOne-hundred six consecutive patients with shoulder pain underwent attempted intra-articular injection either posteriorly, supraclavicularly, or anteriorly. Each approach was performed by an experienced and inexperienced provider. A musculoskeletal radiologist blinded to technique used and provider interpreted fluoroscopic images to determine accuracy. Providers were blinded to these results.nnnRESULTSnThe accuracy of the anterior approach regardless of experience was 64.7%, the posterior approach was 45.7%, and the supraclavicular approach was 45.5%. With each approach, experience did not provide an advantage. For the anterior approach, the experienced provider was 50% accurate compared to 85.7%. For the posterior approach, the experienced provider had a 42.1% accuracy rate compared to 50%. The experienced provider was accurate 50% of the time in the supraclavicular approach compared to 38.5%. The providers were not able to predict their accuracy regardless of experience. The experienced providers, when compared to those who were less experienced, were more likely to be overconfident, particularly with the anterior and supraclavicular approaches.nnnCONCLUSIONnThere was no statistically significant difference between the 3 approaches. The anterior approach was the most accurate, independent of the experience level of the provider. The posterior approach produced the lowest level of confidence regardless of experience. The experienced providers were not able to accurately predict the results of their injections, and were more likely to be overconfident with the anterior and supraclavicular approaches.

Supraspinatus atrophy as a predictor of rotator cuff tear size: an MRI study utilizing the tangent sign.

HYPOTHESISnWe hypothesize that the degree of supraspinatus atrophy, as assessed with the tangent sign will significantly correlate with increasing rotator cuff tear size.nnnMETHODSnA retrospective review was performed assessing presence of muscle atrophy using the tangent sign, fatty atrophy based on Goutallier classification, and size of rotator cuff tear in 34 patients. A correlation analysis was performed.nnnRESULTSnAll agreement measures among both evaluators were statistically significant (P < .05). Agreement among the 2 physicians for the tangent sign was consider almost perfect k = 87.2 (95%CI = 51.7, 87.2). Weighted kappa agreement using the Goutallier sign was 75.1 (95%CI = 58.7, 91.4), suggesting substantial agreement. The relationship between the positive tangent sign and coded tear grade was very good with a correlation of R = .84 and R = .87, respectively, showing a strong correlation between the presence of a tangent sign and a larger rotator cuff tear. A strong relationship was also found when comparing the tangent sign to a Goutalliers classification of 2 or greater with a correlation of R = .92 and R = .94 for the 2 physicians. The lowest correlation was found between the Goutallier sign and tear grade from both physicians. All of these findings were statistically significant (P < .05).nnnCONCLUSIONnThe tangent sign shows good interobserver reliability and is easily performed to measure rotator cuff atrophy and a positive tangent sign shows an excellent correlation with the size of the rotator cuff tear and may be predictive of the ability of the cuff to be primarily repaired.

A positive tangent sign predicts the repairability of rotator cuff tears

HYPOTHESISnWe hypothesize that patients with a positive tangent sign will have rotator cuff tears that are not able to be repaired primarily.nnnMETHODSnWe performed a retrospective review of the charts of patients who had undergone surgery for repair of a rotator cuff tear. The operative note was reviewed to determine whether the cuff tear was primarily repaired. The magnetic resonance imaging study of each patient was reviewed to assess for a positive or negative tangent sign. The reviewer was blinded to the result of each measurement.nnnRESULTSnEighty-one patients met the inclusion criteria. Of the 79 included in our analyses, 17 had a positive tangent sign and 62 had a negative tangent sign. There was only 1 patient with a negative tangent sign who had an irreparable rotator cuff tear. There were 3 patients with a positive tangent sign who had a repairable rotator cuff. With a pretest prevalence of irreparable tears of 18.9%, a positive finding suggested a post-test probability of 82.3% with a positive tangent sign and a post-test probability of only 1.6% when the tangent sign was negative.nnnCONCLUSIONnOur results showed decision-making value in both a negative tangent sign and a positive tangent sign. The tangent sign is an easily performed and reproducible tool with good intraobserver and interobserver reliability that is a powerful predictor of whether a rotator cuff tear will be repairable.

If overuse injury is a ‘training load error’, should undertraining be viewed the same way?

Inappropriately high training loads cause overuse injuries.1 However, it has recently been proposed that overuse injuries should be considered in terms of both ‘overloading’ and ‘underloading’.2 The rationale is that increased injury risk is associated with ‘spikes’ in workload (ie, overloading) and low chronic workloads (ie, underloading), which may leave an athlete predisposed to a ‘spike’ in workload.3 Given that workload is both modifiable and controllable, it has been suggested that ‘overuse injuries’ be considered as ‘training load errors’.2 ,4nnAnecdotally, strength and conditioning staff are viewed as the practitioners who ‘break’ the athlete, while medical staff ‘fix’ them. Conversely, conditioning staff may indeed decrease the probability of athletes sustaining an injury by increasing chronic workloads, whereas medical staff may inadvertently increase injury risk by reducing workloads. Given that all coaching staff as well as the performance team (eg, strength and conditioning, sport scientists and physiotherapists) are involved to varying degrees in the training process, an effective solution needs to be multidisciplinary in nature. Periods of underloading and overloading can occur anywhere, from rehabilitation through to game-specific skills and competition, hence communication between athlete, manager …

Glenoid screw position in the Encore Reverse Shoulder Prosthesis: an anatomic dissection study of screw relationship to surrounding structures

BACKGROUNDnFixation of the baseplate to the glenoid for the Reverse Shoulder Prosthesis (DJO Surgical, Austin, TX, USA) requires secure screw purchase to avoid excessive micromotion and baseplate failure. The best screw length for fixation is unknown. In addition, excessively long screws or a plunge of the drill bit during baseplate insertion could injure surrounding structures.nnnMETHODSnReverse Shoulder Prosthesis baseplates were inserted in 10 fresh-frozen shoulders by use of a 6.5-mm central screw and four 5.0-mm peripheral locking screws placed 90° to the baseplate. The top superior screw was placed into the base of the coracoid, corresponding to the 1-oclock position in a right shoulder. The distances to surrounding vital structures were recorded, screws were removed, and screw hole lengths were measured to determine the most effective lengths in different parts of the glenoid scapula.nnnRESULTSnThe screw length was 30 mm for the superior screw holes, 28 mm for the inferior screw holes, 13 mm for the anterior screw holes, and 15 mm for the posterior screw holes. The central screw trajectory was through the anterior cortex. The anterior screw trajectory violated the subscapularis belly in all specimens. The posterior screw touched the suprascapular nerve or artery in 3 of 10 specimens.nnnDISCUSSIONnThe superior and inferior screws have the longest bony fixation. Drill bit plunge during placement of the anterior screw poses a risk to the subscapularis muscle. Drilling for the posterior screw risks injury to the suprascapular nerve and artery at the spinoglenoid notch.nnnCONCLUSIONSnThe posterior screw should be placed with care to avoid neurovascular complications.

Mathematical coupling causes spurious correlation within the conventional acute-to-chronic workload ratio calculations

The monitoring of training loads is now a much-researched topic in team sports.1 Within this topic, researchers and practitioners are particularly interested in the impact of relatively short (acute) periods of higher training loads normalised for the prior and longerxa0term (chronic) loads. In recent years, a well-established approach for normalising this acute ‘spike’ to chronic load has been by calculating the ‘acute:chronic workload ratio’ (ACWR). Importantly, the term load was retained given its common use in this research area. Both this index and chronic load itself have been reported to be independent predictors of training-related injuries.2 It has also been reported, particularly in team sports competitors, that there are associations between acute spikes in trainingxa0loads (relative to chronic loads) and time-loss injuries.1nnThe ACWR is usually calculated as the simple ratio of recent (ie, 1u2009week) to longer term (ie, 4u2009weeks) training loads.1 While it is important for the numerator and denominator of any ratio to be correlated only through biological mechanisms,3 one aspect of the ACWR calculation is that the acute load also constitutes a substantial …

Resilience correlates with outcomes after total shoulder arthroplasty

BACKGROUNDnResilience, characterized by an ability to bounce back or recover from stress, is increasingly recognized as a psychometric property affecting many outcomes domains including quality of life, suicide risk in active-duty military personnel, and recovery in cancer patients. This study examines the correlation between resilience, as measured by the Brief Resilience Scale (BRS), and traditional outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA).nnnMETHODSnSeventy patients undergoing primary anatomic TSA were followed up for a minimum of 2u2009years (mean, 30u2009±u20093 months). Patients were stratified into groups a priori, based on deviation from the mean of the BRS score, into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients, and outcome scores were calculated for each group.nnnRESULTSnPostoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (ru2009=u20090.41-0.44, Pu2009<u2009.004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, Pu2009=u2009.05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; Pu2009=u2009.03).nnnCONCLUSIONSnResilience is a major predictor of postoperative outcomes after TSA. Patients who are classified as having LR have outcome scores that are 30 to 40 points lower on traditional outcome scales than patients with HR.

Clinical outcomes of suprascapular nerve decompression: a systematic review

BACKGROUNDnSuprascapular neuropathy is an uncommon clinical diagnosis. Although there have been a number of case series reporting on this pathologic process, to date there has been no systematic review of these studies. This study aimed to synthesize the literature on suprascapular neuropathy with regard to clinical outcomes. The secondary objective was to detail the diagnosis and treatment of suprascapular neuropathy and any associated complications.nnnMETHODSnA systematic review was performed to identify studies that reported the results or clinical outcomes of suprascapular nerve decompression. The searches were performed using MEDLINE through PubMed and Cochrane Database of Systematic Reviews.nnnRESULTSnTwenty-one studies comprising 275 patients and 276 shoulders met inclusion criteria. The mean age was 41.9 years, and mean follow-up was 32.5 months. The most common symptom was deep, posterior shoulder pain (97.8%), with a mean duration of symptoms before decompression of 19.0 months; 94% of patients underwent electrodiagnostic testing before decompression, and 85% of patients had results consistent with suprascapular neuropathy. The most common outcome reported was the visual analog scale score, followed by the Constant-Murley score. The mean postoperative Constant-Murley score obtained was 89% of ideal maximum. Ninety-two percent of athletes were able to return to sport. Only 2 (0.74%) complications were reported in the included studies.nnnCONCLUSIONSnSurgical decompression in the setting of suprascapular neuropathy leads to satisfactory outcomes as evidenced by the patient-reported outcomes and return to sport rate. Furthermore, the rate of complications appears to be low.