Stefan J. Tolan

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

BACKGROUND Despite 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. MATERIALS AND METHODS From 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. RESULTS Complications 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. CONCLUSION Repairing 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

BACKGROUND Reverse 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. MATERIALS AND METHODS Eight 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. RESULTS Six 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. CONCLUSION Limited 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

BACKGROUND The 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. METHODS One-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. RESULTS The 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. CONCLUSION There 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.

Comparison of perioperative complications in patients with and without rheumatoid arthritis who receive total elbow replacement

Total elbow replacement is a well-recognized surgical treatment for patients with advanced rheumatoid arthritis (RA) of the elbow. At present, there is minimal literature outlining the perioperative complications associated with total elbow replacement. We endeavored to identify complication rates and hospital disposition differences between patients with and without RA who received a total elbow replacement. Data from the Nationwide Inpatient Sample was used to capture 3,617 patients who received a total elbow arthroplasty between 1988-2005. Of these, 888 had a primary diagnosis of RA and were compared against patients without RA. Analyses addressed perioperative complications and hospital disposition factors, such as charges and length of stay. Overall complication rates were very low with only 2 variables, respiratory complications (P = .01) and renal failure (P = .04) demonstrating significantly worse outcomes in patients without RA (P = .01). Patients without RA had also had longer lengths of stay (P < 0.01). There were 9 reported perioperative deaths. The findings suggest that the perioperative complications of a total elbow replacement for all patients studied are few and that outcomes in patients with RA are nearly equivalent to those in patients without RA.

Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults

BACKGROUND The treatment of 3- and 4-part proximal humeral fractures in the older adult is controversial. No study has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for these fractures. The purpose of this study was to compare clinical and patient-reported outcomes between RSA and nonoperative treatment groups. METHODS A retrospective review was performed on all 3- and 4-part proximal humeral fractures treated with either RSA or nonoperative treatment with minimum 1-year follow-up. All patients in the nonoperative cohort were offered RSA but declined. Objective patient data were obtained from medical records. Patient-reported outcomes including visual analog scale score, Single Assessment Numeric Evaluation score, Penn Shoulder Score, American Shoulder and Elbow Surgeons score, resiliency score, and Veterans Rand-12 scores were obtained at follow-up. Statistical analysis was performed by use of the Student t test for continuous variables and χ2 analysis for nonparametric data. RESULTS We analyzed 19 nonoperative and 20 RSA patients with a mean follow-up period greater than 2 years (29 months in nonoperative group and 53 months in RSA group). There were no differences in range of motion between groups (forward elevation, 120° vs 119° [P = .87]; external rotation, 23° vs 31° [P = .06]). No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes. Among patients receiving RSA, there was no difference in outcomes in those undergoing surgery less than 30 days after injury versus those receiving delayed RSA. CONCLUSIONS This study suggests that there are minimal benefits of RSA over nonoperative treatment for 3- and 4-part proximal humeral fractures in older adults.

Clinical outcomes of suprascapular nerve decompression: a systematic review

BACKGROUND Suprascapular 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. METHODS A 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. RESULTS Twenty-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. CONCLUSIONS Surgical 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.

The incidence and effect of fatty atrophy, positive tangent sign, and rotator cuff tears on outcomes after total shoulder arthroplasty

BACKGROUND Treatment choices for total shoulder arthroplasty (TSA) in the absence of full-thickness rotator cuff tears (RCTs) are not clearly defined in current literature. This study investigated the prevalence and effect of preoperative partial-thickness RCTs and muscular degenerative changes on postoperative outcomes after TSA. METHODS Medical records and magnetic resonance imaging studies were reviewed for patients who underwent TSA for primary glenohumeral osteoarthritis with minimum 2-year follow-up to determine preoperative tear classification, Goutallier grade, and supraspinatus tangent sign. Postoperative pain on the visual analog scale, range of motion, and patient outcomes scores were obtained to correlate preoperative RCT status, Goutallier grading, tangent sign, and postoperative outcomes. Patients with full-thickness RCT on preoperative magnetic resonance imaging were excluded. RESULTS Forty-five patients met all inclusion criteria (average age, 65 ± 10 years; average follow-up, 43 months). Of the patients undergoing TSA, 40% had a significant (>50% thickness) partial RCT. Grade 3 to 4 Goutallier changes were noted in 22% of all patients, and 13% demonstrated grade 3 to 4 changes in the context of no tear. Positive tangent sign was present in 7% of all patients. The preoperative Goutallier grade of the infraspinatus was significantly negatively correlated with postoperative forward elevation (P = .02) and external rotation (P = .05), but rotator cuff pathology, including tear status, Goutallier grade, and the presence of a tangent sign, did not correlate with postoperative functional outcome scores. CONCLUSIONS Even in the absence of a full-thickness RCT, rotator cuff atrophy, fatty infiltration, and partial thickness tearing are common findings. Although postoperative range of motion is correlated to Goutallier changes of the infraspinatus, rotator cuff pathology is not correlated to outcomes after TSA; therefore, one may proceed with TSA without concern of their effect on postoperative outcomes.

Arthroscopic Repair of Posterior Bony Bankart Lesion and Subscapularis Remplissage

Posterior shoulder instability with glenoid bone loss has only a fraction of the prevalence of anterior instability. Unlike the latter, there is a paucity of literature regarding the treatment of posterior bony Bankart lesions and even less with concomitant reverse Hill-Sachs lesions. This combination of pathology leads to a difficult situation regarding treatment options. We present our technique for arthroscopic repair of a posterior bony Bankart lesion and reverse Hill-Sachs lesion. The importance of proper portal placement cannot be overstated. By use of the lateral position and strategically placed portals, the posterior bony Bankart lesion and attached labral complex were appropriately mobilized. We reduced the glenoid bone, with the attached capsulolabral complex, to the glenoid rim and performed fixation using a knotless suture anchor. We then placed 2 double-loaded suture anchors into the reverse Hill-Sachs lesion. The sutures were passed creating horizontal mattress configurations that were tied at the end of the procedure, effectively externalizing the humeral head defect. Our technique results in satisfactory fragment reduction, as well as appropriate capsular tension, and effectively prevents the reverse Hill-Sachs lesion from engaging.

Validity and Responsiveness of the Single Alpha-numeric Evaluation (sane) for Shoulder Patients

Objectives: The is an ever-increasing demand within the emerging health care arena to demonstrate the efficacy of orthopedic interventions. Widespread implementation of patient reported outcomes are limited in part due to the barriers of clinical infrastructure and resources in a busy orthopedic practice. Prior studies have shown the single alpha-numeric evaluation (SANE) score to correlate at a single point in time with the American Shoulder and Elbow Surgeons(ASES) score. However, no study has validated the SANE in terms of test-retest reliability, responsiveness or clinical utility. Therefore, the purpose of this study was to validate SANE compared to the ASES across a sample of patients with the most common orthopedic shoulder diagnoses. Methods: Shoulder patients (n=105 age=52.7 ± 1.2; female=67) undergoing rotator cuff repair (cuff=44), total shoulder replacement (TSA=23), or physical therapy (PT=38) were administered the SANE and ASES less than 14 days apart prior to surgery and again at their 3 month follow up from initial care or surgery. Interclass Correlation Coefficients (ICC(2,1)) and standard error of the measure(SEM) were used to evaluate the test-retest reliability of the SANE and the validity between the SANE and ASES scores. An ANOVA (treatment group by time) was used to evaluate the responsiveness to treatment, and a Receiver Operating Curve was used to establish the minimally important clinical difference (MCID) for the SANE compared to the ASES (α =0.05). Results: The SANE demonstrated good reliability (ICC(2,1) =0.76 ± 3.4) similar to the ASES (ICC(2,1) =0.82 ± 3.4) pre-treatment. The SANE demonstrated good agreement with the SANE across all treatment groups (Cuff= ICC(2,1) 0.85 ± 3.4; TSA- ICC(2,1) =0.72 ± 5.2;PT- ICC(2,1) =0.82 ± 2.9) pre and post treatment. The SANE displayed similar responsiveness to the ASES after treatment (Figure 1) with similar mean change and standard deviations within each treatment group. The ROC curve revealed an area under the curve of .79 (SE, 0.62; P<.001) and a cutoff of 9.5% on the SANE with a sensitivity of 83% and a specificity of 31% to establish the MCID. Conclusion: Our study is the first to demonstrate the SANE is valid across a range of common shoulder diagnoses to assess patient outcomes across operative and non-operative treatment for shoulder complaints. The MCID of 9.5% is similar to the ASES (11%) suggesting that the SANE is a simple and efficient tool to assess treatment effects for shoulder disorders. Future studies are warranted to confirm these results and compare across other body parts and diagnoses.

Treatment of Biceps Lesions in the Setting of the Rotator Cuff Repair: When is Tenodesis Superior to Tenotomy?

Objectives: However, the optimal treatment of biceps pathology is unclear as few studies have compared tenotomy versus tenodesis in the setting of RCTs. Therefore, the purpose of this study is to compare the outcomes of biceps tenodesis versus tenotomy in the setting of RCTs in order to determine if and when an advantage exists for one technique over the other. Methods: We retrospectively reviewed 134 patients(age=59.3± 8.6, males=88) following rotator cuff repair with concomitant biceps procedure and minimum 2-year follow up. Validated outcomes scores, including the American Society of Shoulder and Elbow Surgeons(ASES) score was completed before and after surgery. Patients were stratified by age, RCT size and biceps procedure (tenotomy or tenodesis). Separate mixed model ANOVAs (time by group) were performed to compare ASES scores between biceps procedure groups within each RCT size and age group. Results: There were 91 tenodeses and 43 tenotomies. There were no differences in baseline ASES scores or demographics between the groups(P>0.05). Overall patients displayed improvements in ASES scores(43±13) post-operatively but there were no differences between biceps treatment selection within each RCT size group(P>0.05). However, Patients < 55 years old with RCTs > 4cm and biceps tenodesis(n=18) demonstrated nearly twice the improvement(52±3) in post-operative ASES scores compared to those with a biceps tenotomy(28±14; P=0.03). This difference was not observed in patients > 55 years old or with rotator cuff tears less than 4cm(P=0.56). Conclusion: This is the first study to demonstrate the superiority of tenodesis over tenotomy in setting of RCTs. Specifically, in younger patients with larger tears, tenodesis had nearly double the improvement in ASES score compared to tenotomy. Our results suggest biceps tenodesis should be considered over tenotomy with concurrent greater than 4cm rotator cuff repairs in patients < 55 years old.